HopkinsGeneralSurgeryManual 1

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HopkinsGeneralSurgeryManual 2
Introduction

ThismanualisacompilationofstudynotesIhavemadeoverthepast5yearsbasedona
numberofsources,includingthoselistedhere:

Textbooks(seereferencelist)
Reviewbooks(seereferencelist)
DidacticlecturesandconferencesatbothJohnsHopkinsandtheNCISurgeryBranch
PresentationsIgaveduringweeklyconferencesatNCI
Primaryandreviewarticles
PointsmadebyattendingsandotherresidentsonroundsorintheOR
InternSundaymorninglecturewithDr.Cameron(20012002)
Halstedquizzes
SESAPquestions
UpToDate

Disclaimer:Individualillustrationsandmaterialmaybelongtoathirdparty.
UnlessotherwisestatedallfiguresandtablesbyPeterAttia

WhenIbeganputtingmynotestogetheronrandompiecesofpaperandmyPalmPilot,Ididnot
intendtodomuchelsewiththem.However,intime,theybecamesonumerousthatIneededto
organizetheminabetterway.AresidentfromtheBrighamwhomIworkedwithinthelabat
NIHencouragedmetoputthemtogetherinwhathejokinglyreferredtoasanAttiaBibleof
surgicalwisdom,somethinghehaddonewithhisownnotes.Theintentofthesenoteswasnotas
muchtobeareviewforaspecifictestperse,asitwasanallpurposecompilationofsalient
pointstoconsiderasIgothroughresidency.

Ofcourse,thesenotescomewiththestandarddisclaimerthattheyarenotmeanttoreplace
readingfromprimarysources,rathertosupplementit.Inaddition,whileIhavetriedtobeas
accurateaspossible,duringmyreadingsIencounteredseveralfactsthatwereeither
contradictorytofactsIhadbeentaughtasaresidentorreadinothersources.ForthisreasonI
canmakenoguaranteesaboutthevalidityofeachstatementmadehere.Ihavetriedmybestto
amalgamateeachsetoffactsintoasomewhatconcise,yetaccuratedocument.

Hopefully,thesenoteswillprovideyouwithsomebenefitaswell.Iwelcomeallcriticismand
correctionandlookforwardtosupplementingandaugmentingthisfirsteditionmanytimesover.

PeterAttia,MD
SurgicalResident
TheJohnsHopkinsHospital
pete_attia@yahoo.com

Copyright,PeterAttia,2005.Allrightsreserved.
HopkinsGeneralSurgeryManual 3
ReferenceList

1. VascularSurgery3
rd
Ed.HouseOfficerSeries.FaustGR,CohenJR.,1998.
2. ABSITEKiller.LipkinAP,2000
3. RushUniversityReviewofSurgery3
rd
Ed.Deziel,Witt,Bines,etal.,2000.
4. CurrentSurgicalTherapy6
th
Ed.CameronJL,1998.
5. CurrentTherapyofTrauma4
th
Ed.TrunkeyDDandLewisFR,1999.
6. Surgery:ScientificPrinciplesandPractice3
rd
Ed.GreenfieldLJ,etal.,2001.
7. ShackelfordsSurgeryoftheAlimentaryTract5
th
Ed.YeoCJandZuidemaGD.VolumesIV,2001.
8. AtlasofHumanAnatomy8
th
Ed.NetterFH,1995.
9. AtlasofSurgicalOperations7
th
Ed.Zollinger&Zollinger,1993.
10. GeneralSurgeryBoardReview3
rd
Ed.GoldMS,ScherLA,andWeinbergG,1999.
11. GeneralSurgeryReview.MakaryMA,2004.
12. AdvancesinSurgeryVol33.Ed.CameronJL,etal.,1999.
13. PitfallsofDataAnalysis.ClayHelberg,1995.
14. PrinciplesofBiostatistics.2
nd
Ed.PaganoMandGauvreauK.2000.

Editors

Thefollowingindividualshavebeengenerouswiththeirtimeandthoughts,andhavemadeseveralchangesand
additionstomyoriginalmanual.

H.RichardAlexander SurgeryBranch,NationalCancerInstitute
WilliamA.Baumgartner TheJohnsHopkinsHospital
JohnL.Cameron TheJohnsHopkinsHospital
MichaelA.Choti TheJohnsHopkinsHospital
PeterL.Choyke DepartmentofRadiology,NationalInstitutesofHealth
PaulM.Colombani TheJohnsHopkinsHospital
MatthewCooper TheUniversityofMaryland
EdwardE.Cornwell,III TheJohnsHopkinsHospital
ToddDorman TheJohnsHopkinsHospital
FredericE.Eckhauser TheJohnsHopkinsHospital
DavidT.Efron TheJohnsHopkinsHospital
AnneC.Fischer TheJohnsHopkinsHospital
JulieA.Freischlag TheJohnsHopkinsHospital
SusanL.Gearhart TheJohnsHopkinsHospital
VincentL.Gott TheJohnsHopkinsHospital
McDonaldHorne DepartmentofHematology,NationalInstitutesofHealth
UdaiS.Kammula SurgeryBranch,NationalCancerInstitute
HerbertKotz DepartmentofGynecology,NationalCancerInstitute
StevenK.Libutti SurgeryBranch,NationalCancerInstitute
PamelaA.Lipsett TheJohnsHopkinsHospital
MartinA.Makary TheJohnsHopkinsHospital
BruceJ.Perler TheJohnsHopkinsHospital
PeterA.Pinto UrologyBranch,NationalCancerInstitute
JorgeD.Salazar UniversityofTexas,SanAntonio,TX
AnthonyP.Tufaro TheJohnsHopkinsHospital
PeterS.Walinsky PresbyterianHeartGroup,Albuquerque,NM
StephenS.Yang TheJohnsHopkinsHospital
CharlesJ.Yeo ThomasJeffersonUniversity
MarthaA.Zeiger TheJohnsHopkinsHospital
HopkinsGeneralSurgeryManual 4
TableofContents

BreastDisease................................................................................................................................................................................... 5
Head&NeckDisease...................................................................................................................................................................... 9
ThyroidGlandandDisease ......................................................................................................................................................... 12
ParathyroidGlandandDisease................................................................................................................................................... 15
MultipleEndocrineNeoplasia(MEN) ....................................................................................................................................... 18
Gastrinoma...................................................................................................................................................................................... 21
Glucagonoma.................................................................................................................................................................................. 22
Insulinoma ...................................................................................................................................................................................... 23
AdrenalGland................................................................................................................................................................................ 24
Pheochromocytoma........................................................................................................................................................................ 27
PituitaryGland............................................................................................................................................................................... 28
ThoracicSurgery ............................................................................................................................................................................ 29
MediastinalDisease ...................................................................................................................................................................... 32
CardiacSurgery:CongenitalDefects ......................................................................................................................................... 34
CardiacSurgery:AcquiredDefects............................................................................................................................................. 36
VascularSurgery............................................................................................................................................................................ 42
Urology............................................................................................................................................................................................. 54
OrthopedicSurgery ....................................................................................................................................................................... 55
GynecologicPathology ................................................................................................................................................................. 56
Neurosurgery .................................................................................................................................................................................. 57
CancerEpidemiology .................................................................................................................................................................... 58
EsophagealDisease........................................................................................................................................................................ 59
Stomach&GutPhysiologyandDisease ................................................................................................................................... 63
SmallBowelPhysiologyandDisease ........................................................................................................................................ 67
ColorectalDisease.......................................................................................................................................................................... 71
PediatricSurgery............................................................................................................................................................................ 79
SpleenandSplenectomy .............................................................................................................................................................. 84
HepatobiliaryAnatomy,Physiology,andDisease.................................................................................................................. 86
Pancreas............................................................................................................................................................................................ 97
Sarcoma.......................................................................................................................................................................................... 102
Melanoma...................................................................................................................................................................................... 103
Hernia&AbdominalWall ......................................................................................................................................................... 105
TraumaPrinciples........................................................................................................................................................................ 106
CriticalCare................................................................................................................................................................................... 117
Hemostasis&Transfusion......................................................................................................................................................... 126
Metabolism.................................................................................................................................................................................... 130
TransplantSurgery ...................................................................................................................................................................... 131
Nutrition........................................................................................................................................................................................ 134
Fluids&Electrolytes ................................................................................................................................................................... 136
RenalPhysiology.......................................................................................................................................................................... 137
Immunology/Infections .............................................................................................................................................................. 139
Burns............................................................................................................................................................................................... 140
Skin&WoundHealing............................................................................................................................................................... 141
Pharmacology................................................................................................................................................................................ 142
Radiology....................................................................................................................................................................................... 143
StatisticsinMedicine .................................................................................................................................................................. 149
Notes............................................................................................................................................................................................... 154
HopkinsGeneralSurgeryManual 5
BreastDisease

SurgicalAnatomy:
Intercostobrachialnerve(off2
nd
intercostalnerve)sensationtomedialarmcansacrifice
Longthoracicnerve:toserratusanteriorwingedscapula
Thoracodorsalnerve:tolatissimusdorsiweakarmadduction
Medialpectoralnervetopecminorandmajor;lateralpectoralnervetopecminoronly

Batsonsplexus:valvelessvertebralveinsallowdirectmetastasestospine
Polandsyndrome:amastia,hypoplasticshoulder,nopecs
Mastodynia:Rxwithdanazol,OCP
Mondorsdisease:thrombophlebitisofsuperficialveinofbreastRxwithNSAID

DCIS
Highlycurablewithsurvivalof94100%
50%ofrecurrencesareinvasive
ExcisionandradiotherapyORmastectomy;axillarylymphnodedissection(ALND)notrequired
(only1%havepositivenodes).NSABP17showedthatlumpectomyalonehad13.4%recurrent
DCISand13.4%recurrentinvasivecancervs.8.2%and3.9%,respectivelyforlumpectomy+
radiation.
TamoxifendecreasesrateofipsilateralandcontralateralbreastcancerinERpositivewomen,rolein
ERnegativewomen,ifany,unknown;butmustbebalancedagainstriskfactors(12%DVT,PE;
Endometrialcancer).TamoxifenhasNOTbeenshowntoincreasesurvival,onlytodecreaserate
ofrecurrence(DCISandipsilateral/contralateralinvasivebreastcancer).Severallargestudies
havebeendone(NSABP24,1800patients,[FisherB,etal.Lancet1999;353:1993])andfailedtoidentifya
survivaladvantage,despiteadequatepower.
Ongoingresearchtoidentifysubsetofpatientswhocouldbetreatedwithoutradiation
RoleofSentinelLymphisundefined.NOevidencetosupportuseasof2004.
VanNuysclassificationMAYidentifypatientswhocanbenefitfromlumpectomyalone(lowgrade,
withoutnecrosis;margin>1cm;lesion<1.5cm)

LCIS
1. AkaLobularNeoplasia,encompassesLCIS(>50%lobularinvolvement)andAtypicalLobular
Hyperplasia(ALH,<50%lobularinvolvement)
2. Notclinically,radiographically,grosslydetectable
3. 710xincreasedriskofinvasivecancerineitherbreast(especiallyinyoungwomenwithafamily
history)
4. 17%riskat15years,5.6%at5years;20%lifetimerisk(70%ofwhichwillbeductalinvasive,30%
willbelobularinvasive);1%peryear
5. Marginsareirrelevant,diseaseisdiffuse(unlikeDCIS)
6. LCISisnotitselfprecancerous,itissimplyamarkerofasusceptiblefield

Phyllodestumor:10%malignant;large;rarenodes(spread,ifany,hematogenous):RxWLE,mastectomy
notnecessary;NOALND

Intraductalpapilloma:Noriskofcancer;#1causeofbloodynippledischarge

HopkinsGeneralSurgeryManual 6
Comedobreastcancer:Likelymulticentric;domastectomy;poorprognosis

Pagetsdiseaseofthebreast:EczematouslesiononnippleunderlyingDCISorductalCA

Mostrecentscreeningrecommendations:Firstat40;q12yearsuntil50;yearlythereafter

RadialScar:associatedwithcarcinomaanywhereinthescar;donotstereotacticallybiopsy(chanceof
samplingerror),insteadexcisionalbiopsy

Staging:
T1:<2cmT2:2.15cmT3:>5cmT4:skininvolvement(inflammatorydermallymphaticinvasion)

N1:+axnodes N2:matted/fixed N3:internalmammarynodes

StageI:T1 StageII:uptoT2N1orT3N0 StageIII:T4orN3 StageIV:anyM

Survivalbystage(5years):
I:9095% II:5080% III:3050% IV:1520%

Note:FNAcannotdistinguishbetweenDCISandinvasive

Whogetschemotherapy?
1.Premenopausal:
ER/PR
T>1cm
AnyN,includingmicro(SN+)
2.Postmenopausal(upto90%areER/PR+gettamoxifen):
ER/PR&T>2cm
4nodesORmattednodes(regardlessofER/PR)
(Hence,ER/PR+,3unmattednodesnochemo)

Whogetsaxillaryradiation?(Ingeneral,wanttoavoidaxillaryradiationfollowingdissection)
+supraclavicularnode
mattednodes(extracapsularextension)
4nodes

Whogetsbreastirradiation?
anysegmentalresectionforinvasiveorDCIS
inflammatorydisease(T4/skininvolvement);someT3

Majorstudiesevaluatingroleofadjuvantradiation*therapy:

1. Theadditionofpostopirradiationtochemotherapy(CMF)forwomenwithstageIIorIIIbreast
cancerfollowingmastectomyincreasedoverallsurvivalandreducedlocoregionalrecurrence.
[Postoperativeradiotherapyinhighriskpremenopausalwomenwithbreastcancerwhoreceiveadjuvantchemotherapy.
DanishBreastCancerCooperativeGroup82bTrial.OvergaardM,etal.NEJM1997;337:949].
2. Radiotherapycombinedwithchemotherapy(CMF)aftermodifiedradicalmastectomydecreases
ratesoflocoregionalandsystemicrelapseandreducesmortalityfrombreastcancer.[Adjuvant
radiotherapyandchemotherapyinnodepositivepremenopausalwomenwithbreastcancer.RagazJ,etal.NEJM
1997;337:956].
*Trentalisveryeffectiveintreatingradiationmastitis
HopkinsGeneralSurgeryManual 7
LocallyAdvancedBreastCancer
LocallyAdvancedBreastCancer(LABC)&InflammatoryBreastCancer(IBC)sometimes
(incorrectly)usedinterchangeably
Strictlyspeaking,LABCincludes:T3+N13orT4+N03oranyT+N23(i.e.StageIIIA/Bdisease)
TermIBCfirstusedin1924byLeeandTannenbaumatMemorialHospitaltodescribeclinical
presentationof28patientswith:breastofaffectedsideusuallyincreasedinsizeskinbecomes
deepredorreddishpurpletothetouchbrawnyandinfiltratedafterthefashionoferysipelas
Accountsfor16%ofallbreastcarcinomas(IBC)
5075%axillaryinvolvementatdiagnosis

Overallprognosismediansurvival:2years
DiagnosisbasedonhistologyofinvasivecarcinomaPLUS
1. Erythema
2. Edema,orpeaudorange
3. Wheals,orridgingoftheskinsecondarytodermallymphaticinvasion(althoughtumor
invasiononlyseenin30%)
Neoadjuvanttreatmentandearlydiagnosiscrucialforsuccessfultreatment
Approximately75%undergoCRorPRtoinductiontherapyresponsepredictsoutcome

EffectivenessofmastectomybyresponsetoinductionchemotherapyforcontrolofInflammatoryBreast
Cancer[FlemingR,etal.AnnSurgOnc19974:452]

InitialResponsetoInductiontherapy:
CRmediansurvival:120months(12%)
PRmediansurvival:48months(62%)
NRmediansurvival:<24months(26%)
FurtherBreakdown:
If>1cm
3
residualtumormediansurvival:36months
If<1cm
3
residualtumor70%aliveat5years

RoleofMastectomy:
IfCRorPRChemo+RT+Mastectomyincreasedmediansurvivalfrom48to120months(vs.
Chemo+RT)
IfNRChemo+RT+Mastectomydidnotinfluencemediansurvival(<24months),ordisease
freeinterval

SummaryforTreatmentforInflammatorybreastcancer:
1.Neoadjuvantchemo(cytoxan/adriamycin);responsetothispredictssurvival(10%CR,80%PR)
2.MRM(ifPRorCR)
3.Adjuvantchemo(taxanebased)
4.Radiationtochestwall

HopkinsGeneralSurgeryManual 8
Chemotherapy/Hormonal*Treatment:

Premenopausal Postmenopausal
chemoforalmostanytumor>1cm(regardlessof
nodalstatus)
cytoxan&adriamycin
addtaxaneifnodepositive
tamoxifenifER/PRpositive
arimidexandaromataseinhibitorsnoteffectivein
premenopausalsincecantcompetewith
estrogenproduced
tamoxifenorarimidexifnodenegativeandER/PR+
Chemoifpoorlydifferentiatedand>1cm(evenifnode
negative)
cytoxan&adriamycintaxaneifnodepositive
tamoxifenoradriamycinifelderly,nodepositive,and
ER/PR+

*Responsestohormonaltherapybymarker:
ER/PR+ 80%
ER/PR+ 45%
ER+/PR 35%
ER/PR 10%

InheritedBreastCancerSyndromes:4appeartobeimportant

1.LiFraumeniSyndromemutationofp53
2.Mutationofbcl2(18q21)expressionofbcl2,whichisantiapoptotic
3.BRCA1onlongarmof17
4.BRCA2onshortregionof13q1213

BRCA1
Ch17q21;reported1990,positionallycloned1994
Riskofbreastcancer(85%)andovariancancer(4050%)

BRCA2
Ch13q1213;reported1994;positionallycloned1995
Riskofbreastcancer(85%)andovariancancer(10%)
Riskofmalebreastcancer(6%)

RisksofTamoxifenuse
Uterineadenocarcinoma,sarcoma
Cataracts
DVT,PE
osteoporosis
Nochangeinincidenceofheartdisease
HopkinsGeneralSurgeryManual 9
Head&NeckDisease

Parotiditis:Usuallycausedstaphspp;seeninelderly,dehydrated;Rx:antibioticsdrainageofabscessif
notimproving

Ludwigsangina:Sublingualspaceinfection(severedeepsofttissueinfectionofneckinvolvingthefloor
ofthemouth);ifairwaycompromiseperformawaketracheostomyunderlocalanestheticoperative
debridement

Leukoplakiacanbepremalignant;erythroplakiaispremalignant(andofmuchmoreconcern)

Head&NeckSCC: StageI,II(upto4cm,nonodes)singlemodalitytreatment(surgeryorRT)
StageIII,IVcombinedmodality
PerformFNA,notexcisionalbiopsyforsuspiciousmasses

NasopharyngealSCC:associatedwithEBV;50%presentlateasneckmass;drainagetoposteriorneck
nodes;mostcommonnasopharyngealcancerinadults(lymphomaismostcommoninkids).Oftenseein
Asianpopulation

GlotticCancer:ifcordsnotfixedRT;iffixedsurgery+RT.Chemo+RTusedmoreoftenfororgan
preservation

LipCancer(99%epidermoid[i.e.squamous]carcinoma):Lower>upperlip(becauseofsunexposure)
resectwithprimaryclosureif<lip;otherwiseflap

TongueCancer:usuallysurgery+RT;seeninPlummerVinson(dysphagia,spoonfingers,anemia).More
commonlyseeninsmokers/drinkers

Assalivaryglandsize[sublingual(60%),submandibular(50%),parotid(20%)]incidenceofmalignant
disease

Pharyngealcancershaveworseprognosisthanoralcancers

Mucoepidermoidcarcinoma:#1malignantsalivarytumoroverall

Adenoidcysticcarcinoma:#1malignantsalivarytumorofsubmandibular/minorglands.Overall:poor
prognosis

Pleomorphicadenomamixedparotidtumor=#1benigntumor(4070%ofallsalivaryglandtumors)
DoNOTenucleate(orwillrecur)needssuperficialparotidectomy(spareCNVII).
Ifmalignanttakewholegland+CNVII;
Ifhighgrade(anaplastic)needneckdissection

Warthinstumor(adenolymphoma)#2benignsalivarytumor;malepredominance;10%bilateral;70%of
bilateralparotidtumorsareWarthinstumor;Rxsuperficialparotidectomy

FreysSyndrome:latecomplicationofparotidectomy(occurs50%whenfacialnerveispreserved);perfuse
perspirationovercheekfollowingsalivarystimulation.IntracutaneousinjectionofBotoxA100%effective
intreatment,butresponsesmaybeshortlived(canberepeated).Usuallyselflimiting.

Ipsilateraldroolingfollowingsubmandibularglandresection:likelyinjurytomarginalmandibularnerve

Radicalneckdissection:takesCNXI,SCM,IJ,submandibulargland;mostmorbidisCNXI

HopkinsGeneralSurgeryManual 10
ClassificationofCervicalLymphNodes

Level Nodes
I Submental,submandibularnodes
II UpperIJnodes
III MiddleIJnodes
IV LowerIJnodes
V Spinalaccessorynodes,Transversecervicalnodes
VI Treacheoesophagealgrovenodes
[ACSSurgeryPrinciplesandPractice,2004]
HopkinsGeneralSurgeryManual 11
CancersoftheoralcavityusuallymetastasizetothenodesinlevelsIIII.
LaryngealcancerstypicallymetastasizetothenodesinlevelsIIIV.

PresenceofHornerSyndrome(paralysisofthevagusnerve,phrenicnerve,invasionofbrachialplexus,
and/orparavertebralmusculature)generallyindicatestumorunresectability

Tracheoinnominatefistula
Massivebleedingfromtracheaisinnominatearteryuntilprovenotherwise;avoidbymaking
tracheostomynolowerthan3
rd
ring
Usuallyoccurs23weeksposttracheostomy;poornutritionandsteroidsusemaycontribute
Mortality80%
SentinelbleedtoORforbronchoscopy
Temporarycontrol(onroutetoOR)viacuffhyperinflationorfingercompressionofinnominate
artery(anteriorpressure)
Treatmentisligationofinnominateartery

Mostcommonlocationsformandibularfractures:angle(25%)andsubcondyl(30%);themostcommon
longtermcomplicationofmandibularfractureismalocclusion

Carotidbody:chemoreceptorwithintheadventitiaoftheCCA(posteromedialside);respondstoO2
tension,CO2tension,bloodacidity,andbloodtemperaturebyHR,BP,andrate&depthof
respirationinanattempttoovercometheabovestimuli

Carotidsinus:pressuresensorwithinwallofproximalICA;respondstoBPbyHRandBP
HopkinsGeneralSurgeryManual 12
ThyroidGlandandDisease

fromtheGreekworkTheros(shield)andeidos(form)
secreteshormones(T4,T3,calcitonin)frombasalmembraneside(intobloodstream)
antithyroidagentsimpair(i)iodinationand(ii)couplingofDIT/MIT
T4T3peripherally(kidney,liver)(T3;10xmoreactivethanT4).Propothiouracil(PTU)blocks
peripheralconversionofT4T3
Note:SuppressionofiodineuptakeinpatientswithincreasedT3andT4levelsispathognomonicfor
subacutethyroiditis

UsualCausesofHyperthyroidism:
1. Toxicnodule
2. Toxicmultinodulargoiter
3. Gravesdisease
4. Earlysubacutethyroiditis

WaystoTreatHyperthyroidism:
1. Medical(PTU,methimazole):interferewithiodineconversion;upto60%recur
2. RadioiodineAblation(I
131
):weekstomonths;1
st
choicebymanyexceptinpregnancy
3. Surgery:risksofsurgery

ThyroidStorm:untreatedhyperthyroidism+stress(trauma,infection,pregnancy,DKA,etc)
Rx:fluids,O2,glucose,antithyroiddrugs,butfirsttreatunderlyingcause;
NB:donotuseASA,asitdisplacesT4fromthyroglobulin

(Differentiated)ThyroidCancer
15,00020,000cases/yrUS
15,000,000nodules/yr(510%harborcancer)
mortality<1%

Risks
age<14,>65
previousthyroidcancer
familyhistory
enlargingnoduleonthyroidhormonesuppression
exposuretolowdoseradiation
Gravesdiseaseorthyroiditis
syndromes(MENII,Carneys)

CancerHistology
Papillary(60%)
Follicularvariantofpapillary(20%)
Follicular(<5%)*
Hrthlecellcarcinoma(<5%)
Medullary(5%)
Anaplastic(1%)
Other(1%)
*difficultonFNAtodifferentiatefollicularadenomafromcarcinoma

HopkinsGeneralSurgeryManual 13
OfFNAedlesionsinadults*
Inadequate,
15%
Carcinoma,
5%
Suspicious,
10%
Benign,70%

*Childrenhavehigherincidenceofcarcinoma:2050%

OneoptionforlesionsdeemedbenignonFNAishormonesuppression:ifregressesfollow;
Ifgrowsremove;ifsamerepeatFNA

Surgicalmanagement
Lobectomy:unclearpath(gobackforcompletion,ifnecessary)
Lobectomy+isthmusectomy:papillary<1cm,benignunilaterallesionsorsuspiciouslesions
Totalthyroidectomy(followedbyRAI):papillary1cm,follicular,Hrthle,medullary
IFplanningpostopRAImustdototalthyroidectomy,regardlessofsize(RAIonlyusefulinwell
differentiatedcancersnotMTC)
Medullaryistheonlyhistologywhereyoudocentraldissection(levelVIandVII)prophylactically(in
additiontototalthyroidectomy)andmodifiedradicalneckdissection(levelsIIV)onaffectedside
*PerformingatotalthyroidectomyallowsuseofthyroglobulinforrecurrencemonitoringanduseofRAI
formicroscopicdisease

[FiguretakenfromtalkgivenbyH.R.Alexander,NCI,2003]
HopkinsGeneralSurgeryManual 14
MedullaryThyroidCancer:20%ofthosewithMTChaveMENII(100%ofthosewithMENIIhaveMTC).
MENIIassociatedMTCtendstobebilateral,younger,worseprognosis,RETprotooncogene;
aggressivenessasfollows:MENIIB[performthyroidectomyby6monthsold]>MENIIA[perform
thyroidectomyby5yearsold]>FMTC
Mayseeamyloidonpathology
serumcalcitonin(canuseserumcalcitoninlevelstomonitorforrecurrence)
OriginatesfromparafollicularCcells,whichproducecalcitoninandhencedonotconcentrate
iodine.

Anaplastic:Onlyoperationthatshouldbeconsideredistracheostomy.Minimalroleforpalliativeresection

Medicalmanagement
Thyroidhormonesuppression
Radioactiveiodineablation(RIA)
Cytomel(T3)[halflife34days]vs.Synthroid(T4)[halflife4weeks]
*HenceuseT3replacementpostopbeforeRIA

Thyroglobulincanonlyserveasatumormarkerwhenthefollowing2conditionsaremet:
1. Thetumoriswelldifferentiated(sinceitsproducedbyfollicularcells)
2. Thepatienthashadatotalthyroidectomy

Lymphnodes
Fordifferentiatedcancer:noroleforprophylacticLNDonlyforpalpableorFNA+nodesregional
dissection(RadicaltakeslevelsIVI+jugular+CNXI;ModifiedtakeslevelsIIVII,sparesIJV,SCM,
spinalaccessorynerveXI).LevelsmostatriskareIIVI

Prognosis(forwelldifferentiatedthyroidcancer):
AGES/AMES:age,grade/mets,extent,size;TNM;
However,age,grade(histology),sizemostimportant
Age(>45,or<14)issinglegreatestfactor

Superiorlaryngealnerve(bothsensoryandmotor),Externalbranch:motortocricothyroid;injurylose
projection,highpitchtone;providessensorytosupraglottis
Recurrentlaryngealnerve:innervatesalloflarynxexceptcricothyroid;bilateralinjuryairwayocclusion
Note:AlwaysassesscordfunctionbeforeanyoperationonthyroidtodocumentRLNfunction
HopkinsGeneralSurgeryManual 15
ParathyroidGlandandDisease

Superiorparathyroidglandsfrom4
th
pharyngealpouch;Inferior(andthymus)from3
rd
pharyngealpouch
morevariableposition(sincelongerdistancetraveled)
Allparathyroidglandsgenerallyreceivebloodsupplyfromtheinferiorthyroidartery

Ifonly3glandsfoundatsurgery,fourthmaybein:
Thymus,anteriormediastinum
Thyroid
Carotidsheath
Tracheoesophagealgroove*,posteriormediastinum
Behindesophagus
*Mostcommonectopicsite

PTHproducedbyChiefcellsincreasesCa
++
viabonebreakdown,GIabsorption,increasedkidneyre
absorption,excretionofphosphatebykidney

Hyperparathyroidism
1. Primary:PTHsecretionbyparathyroid(highCa
++
,lowPO4;lookforCl

/PO4>33,evenwith
normalCa
++
)
2. Secondary:PTHsecretionduetorenalfailureordecreasedGICa
++
abs(Ca
++
lowornormal)
3. Tertiary:PTHaftercorrectionof2hyperparathyroidism(highCa
++
)
4. FamilialHypercalcemiaHypocaluria(FHH):see serumCa
++
,PTH,buturineCa
++
(defectinset
pointfornormalCa
++
levels;patientsdonotexperiencethesequelaeofelevatedCa
++
);Nosurgery

ParathyroidImagining:
Sestamibiscan
U/S

201
Technetiumthalliumsubtractionscan
CT/MRI

PrimaryHyperparathyroidism
Incidence:1/4000
Risks:MENI,IIa,irradiation,familyhistory(autosomaldominant)
Adenoma>85%[1],Hyperplasia10%[4],Carcinoma1%[1], [#glandstypicallyinvolved]
Typically:[Cl

]/[PO4]>33

Initialmedicaltreatment:IVfluids,lasix,NOTthiazides

Treatment
1Adenoma:Surgicallyremoveadenoma(biopsyallenlargedglands)
1Hyperplasia:BilateralneckexplorationandintraoperativePTH.Subtotalparathyroidectomy
(leavelowerglandinsitu)ortotalparathyroidectomywithautotransplantation
1Carcinoma:WLEwithipsilateralthyroidectomyandlymphnodedissection

2:CorrectCa
++
andPO4,performrenaltransplant(noparathyroidsurgery)

3:CorrectCa
++
andPO4,performrenaltransplant,removeparathyroidglandsandreimplant30to
40mginforearm

HopkinsGeneralSurgeryManual 16
ParathyroidCarcinoma
Signs/Sx:HyperCa
++
,elevatedPTH,palpablegland(50%),neckpain,recurrentlaryngealnerveparalysis
HCGisamarker
Treatment:Enblocresectionincludingipsilateralthyroidlobe+associatedlymphnodes

PostopComplications:
Recurrentlaryngealnerveinjury
Neckhematoma(openatbedsideifbreathingcompromised)
HypoCa
++

ParathyroidPearls

90%ofprimaryhyperparathyroidismduetoasingleadenomaunilateralexposureisok(with
intraopPTH)

MUSTexcludefamilial/MENdisease(adifferententityaltogetherwhichrequiressubtotal
parathyroidectomyleaveofalowerglandinsitu)

Nuclearmedicineexpertiseiscrucial:ifpossible,subtractionofTc
99m
pertechnetate(potassium
analogspecificforthyroid)fromTc
99m
Sestamibi(takenupbyboththyroidandparathyroid)

ForintraopPTHtobevalidmusthave>50%dropinbaselinePTHwithin10minutes

IntraopPTHmustbeusedifdoingsingleglandexploration(MIP),elsemustdo4gland
exploration

Ifdiseaserecurs,MUSTdistinguishbetweenpersistentandrecurrent:

Persistent:Onlytransientcure.Almostalwaysimpliesmissedadenoma.#1placeisTEgrooveon
rightside;alsoconsiderectopicglands

Recurrent(>6monthsnormocalcemia):Implieshyperplasiawithregrowth(e.g.familial,possibly
cancer)

10xincreaseinRLNinjuryduringredosurgery.Hence,firststepinredoisconfirmdiagnosis
with24hoururinaryCa
++
(ifnormalnodisease).Second,checkforfamilyhistoryofMENI
manifestations

LocalizationwithSestamibiandU/S.ConsiderCT/MRI(verybrightonT2todifferentiatefrom
LNs)

HopkinsGeneralSurgeryManual 17
Ultimatepearls:
Superiorglandsisreallyamisnomer,theyshouldbecalledPosteriorglands,sincetheyarevirtually
alwaysposteriorandcephaladtotheRLN.EctopicsitesaregenerallyposteriorinTEgrove

InferiorglandsshouldbecalledAnteriorglandssincetheyarevirtuallyalwaysanteriorandcaudalto
theRLN.Ectopicglandsareusuallyanterior/mediastinal

Thefigurebelowshowsindottedlinesthepossiblelocationsfortheparathyroidglandsinrelationtothe
RLN.Thereissignificantverticaloverlap,suchthatsuperiorglandscanactuallybebelowinferiorglands,
andviceversa.

HopkinsGeneralSurgeryManual 18
MultipleEndocrineNeoplasia(MEN)

*inheritedautosomaldominant(withvariablepenetrance)

MENTypeI
akaWermersSyndrome(PPP)
ParathyroidHyperplasia(90%)
HyperCa
++
usuallyfirst
Pancreaticisletcelltumors(67%)
Gastrinoma(ZES)(50%)
Insulinoma(20%)
PituitaryTumor(67%)mostoftenPLsecretingtumor

MENTypeIIA
akaSipplesSyndrome(MPP)
MedullaryThyroidCarcinoma(100%)2
nd
to3
rd
decade
calcitoninsecreting
usuallyquiteindolent
Pheochromocytoma(>33%)
catecholexcess
usuallybenign,bilateral,adrenal
ParathyroidHyperplasia(50%)
hyperCa
++

MENTypeIIB
MMMP
MucosalNeuromas(100%)
naso,oropharynx,larynx,conjunctiva
MedullaryThyroidCarcinoma(85%)
moreaggressivethanIIA
Marfanoidbodyhabitus
Pheochromocytoma(50%)
oftenbilateral(70%)

MEN1ConsensusSummaryStatements(lossoffunction)

Diversearrayofdefects(missense,nonsense,frameshift,mRNAsplicing);hencedifficultto
screenbecauseofsomanypossiblemutations

1997:geneMeninfoundofCh11.Exactfunctionunknown,butitisatumorsuppressorgene

TheMEN1germlinemutationtestisrecommendedforMEN1carrieridentification.

AllkindredwithMEN1arelikelytohaveamutationintheMEN1gene.

However,MEN1germlinemutationtestsfailtodetect1020%ofmutations.Ifafamilylacksan
identifiableMEN1mutation,11q13haplotypetestingabouttheMEN1locusorgeneticlinkage
analysiscanidentifyMEN1carriers.PeriodicbiochemicaltestingisanalternativewhenDNAbased
testsarenotpossible.

HopkinsGeneralSurgeryManual 19
ThemaincandidatesforMEN1mutationanalysisincludeindexcaseswithMEN1,theirunaffected
relatives,andsomecaseswithfeaturesatypicalforMEN1.

MEN1carrieranalysisshouldbeusedmainlyforinformation.Itshouldrarelydetermineamajor
intervention.

MEN1tumorpatternsinfamiliesdonothaveclearvariantsorspecificcorrelationswithanMEN1
germlinemutationpattern.Thus,theMEN1carriersinafamilywitheithertypicaloratypical
expressionofMEN1shouldbemonitoredsimilarlyfortypicalexpressionsofMEN1tumors.

MEN1tumorscausemorbiditythroughhormoneexcess(PTH,gastrin,PRL,etc.)andthrough
malignancies(gastrinoma/isletcellorforegutcarcinoid).

Medicationscontrolmostfeaturesofhormoneexcess(gastrin,PRL,etc.).Surgeryshouldcontrol
featuresofexcessofsomeotherhormones(PTHandinsulin).Surgeryhasnotbeenshownto
preventorcureMEN1relatedcancers.

Hyperparathyroidismdevelopsinover90%ofMEN1carriers.Thereiscontroversyoverindications
forparathyroidsurgeryinMEN1patients.

ThepreferredparathyroidoperationintheHPTofMEN1issubtotalparathyroidectomy(without
autograft);transcervicalneartotalthymectomyisalsosimultaneously.Parathyroidtissueshouldbe
cryopreserved.

CurativesurgeryforgastrinomainMEN1israre.Thereiscontroversyovertheindicationsfor
surgeryforgastrinomasinMEN1.

SurgeryinMEN1isindicatedandisusuallysuccessfulforinsulinoma.Formostotherpancreatic
islettumors,exceptgastrinomas,surgeryisalsoindicated;however,thereisnoconsensusover
tumorcriteriaforthelatteroperations.

ThemanagementofpituitarytumorinMEN1shouldbesimilartothatinsporadiccases.

MEN2ConsensusSummaryStatements(gainoffunction)

1995:RETprotooncogene(responsiblefortyrosinekinaseactivity)identifiedonCh10

Fewerpossiblemutations(codons609,611,618,620,634;involvereplacementofacystineresidue)

ThemainmorbidityfromMEN2isMTC.MEN2variantsdifferinaggressivenessofMTC,in
decreasingorderasfollows:MEN2B>MEN2A>FMTC.

MEN2carrierdetectionshouldbethebasisforrecommendingthyroidectomytopreventorcure
MTC.Thiscarriertestingismandatoryinallchildrenat50%risk.

ComparedwithRETmutationtesting,immunoassayofbasalorstimulatedCTresultsinmore
frequentfalsepositivediagnosesanddelaysofthetruepositivediagnosisoftheMEN2carrierstate.
However,theCTteststillshouldbeusedtomonitorthetumorstatusofMTC.

RETgermlinemutation(10q1112)testinghasreplacedCTtestingasthebasisforcarrierdiagnosis
inMEN2families.ItrevealsaRETmutationinover95%ofMEN2indexcases.

TheRETcodonmutationscanbestratifiedintothreelevelsofriskfromMTC.Thesethreecategories
predicttheMEN2syndromicvariant,theageofonsetofMTC,andtheaggressivenessofMTC.

HopkinsGeneralSurgeryManual 20
Thyroidectomyshouldbeperformedbeforeage6monthsinMEN2B,perhapsmuchearlier,and
beforeage5yrinMEN2A.Policiesaboutcentrallymphnodedissectionatinitialthyroidectomyare
controversialandmaydifferamongtheMEN2variants.

MEN2hasdistinctivevariants.MEN2AandMEN2BaretheMEN2variantswiththegreatest
syndromicconsistency.

FMTCisthemildestvariantofMEN2.ToavoidmissingadiagnosisofMEN2Awithitsriskof
pheochromocytoma,physiciansshoulddiagnoseFMTConlyfromrigorouscriteria.

MorbidityfrompheochromocytomainMEN2hasbeenmarkedlydecreasedbyimproved
recognitionandmanagement.ThepreferredtreatmentforunilateralpheochromocytomainMEN2is
laparoscopicadrenalectomy.

HPTislessintenseinMEN2thaninMEN1.Parathyroidectomyshouldbethesameasinother
disorderswithmultipleparathyroidtumors.

HopkinsGeneralSurgeryManual 21
Gastrinoma

50%ofpatientswithMENIhaveagastrinoma
33%ofpatientswithZEShaveMENI(ClinicalTriad:1.PUD2.gastricacidhypersecretion3.Islet
celltumor)
InMENIassociatedZES:Mostcommonsiteisduodenum(2
nd
ispancreas)
aremalignant
25%ofpatientswithpheochromocytomahaveZES
Riskofmetastaticbehaviorfromgastrinomarisessharplyat3cm(<3cm<2%chanceofmets)

ThesporadicdiseaseisadifferentonefromtheMENassociatedone
SporadicZESoccursoutsideoftheduodenum3060%ofthetime;MENversionisvirtuallyalways
intheduodenum(withorwithoutpancreaticinvolvement)
SporadicZESismuchmorelikelytobemalignant(theextrapancreaticprimariesareless
biologicallyaggressiveinbothdiseases)
SporadicZESismoreoftensolitaryandlargeratthetimeofdetection,usually>2cm
MENZESisadiffusedisease,rarelyamenabletotruecure

GastrinomaTrianglejoins:
1.junctionofcysticduct&CBD
2.junctionof2
nd
and3
rd
portionduodenum
3.junctionofneck&bodyofpancreas
(90%foundinthistriangle)[AmJSurg1984147:25Stabile,Morrow,Passaro]

Ddxforincreasedgastrin:
Gastrinoma
Retainedexcludedantrum(asurgicalmistake)
Gastricoutletobstruction
AntralGcellhyperplasia/hyperfunction
Postvagotomy
Perniciousanemia
Atrophicgastritis
Shortgutsyndrome
Renalfailure
H2blocker,protonpumpinhibitor*
*pH<2inhibitsgastrinsecretioninnormalpatients

Checkgastrinlevelsinpatientswith: 1.recurrentulcers
2.ulcersinunusualplaces(e.g.jejunum),
3.refractorytomedicalmanagement
4.priortoanyelectiveoperationforanulcer
5.unexplainedorpersistentdiarrhea
6.pepticulcerandanyendocrinopathy
7.familyhistoryofPUD
8.familyhistoryofMENI

Check:1.fastinggastrinlevel
2.postsecretinchallengegastrinlevel(syntheticsecretin2units/kgIVbolus)
3.Ca
++
(MENIscreen)
4.Chemistrypanel
Highacid
Low/minimalacid
HopkinsGeneralSurgeryManual 22

Lookfor:
ZESfasting:2001000pg/mL(normal<100pg/mL)
Basalacidsecretion:ZES>15mEq/hr(normal<10mEq/hr)
Note:generallywillseefailureoffeedback:fastinggastrin1000withgastricpH<2.5

SecretinStimulationTest:
IVsecretinadministered,gastrinmeasured
ZES:increasedgastrin(by>200pg/mL)within10to20minutes(normalresponseisdecreasein
gastrin)

Managementissues:
SomebelievedistalpancreatectomyshouldbedoneinanypatientwithMENIwitheitherhormonal
syndromeoraneuroendocrinetumorregardlessoflocationinpancreasorduodenum.Virtuallyall
patientswithMENIZEShaveconcomitantneuroendocrinetumorsinneck,body,ortail.
IfpatienthasgastrinomaandhyperparathyroidismremoveparathyroidfirsttonormalizeCa
++

levels(sincehypercalcemiaismoredangerousthanhypergastrinemia)
HigherthannormaldosesofPPIareneededforachlorhydria
MinimalroleforCTscan/octreoscan
ImamuraTest:intraarterialsecretinintovisceralarteriestomeasurehepaticveingastrinlevels
(lookforstepup)isgoodforlocalization
Norolefordebulkingfunctionalgastrinomamets,sincepatientscanbemanagedmedicallyinthis
settingwithPPIs

PostOp
Muststayonacidsuppressionfor34monthsbecauseevenafterresectionacidsecretionhighforsome
time

Glucagonoma

The4DSyndrome:diabetes,diarrhea,dementia,dermatitis(patientslookcachectic)
Manypatientsalsohavenormochromicnormocyticanemia,hypoalbuminemia,weightloss,beefyred
tongue(glossitis),stomatitis,angularchelosis(i.e.signsofmalnutrition)

Usuallyfoundintailofpancreas,butcanbeanywhere.Usually>3cmattimeofdiagnosis;70%malignant

Diagnosissimplebymeasuringserumglucagonlevel,althoughmostpatientswithelevatedglucagonsdo
nothavegastrinoma[seereview:WermersRA,etal.Medicine(Baltimore).1996;75:53]

Sx:NecrotizingMigratoryErythemaNME(usuallybelowwaist),glossitis,stomatitis,diabetes

IVTolbutamideresultsinelevatedglucagon

MedicaltreatmentforNecrotizingmigratoryerythema:Somatostatin/octreotide,IVAminoacids
(TPN)

Aggressivesurgicalresectionsareindicated,evenifmetastatic

HopkinsGeneralSurgeryManual 23
Insulinoma

Number1isletcellneoplasm;associatedwithMENI

8090%arebenignsolitaryadenomascuredbysurgicalresection
30%<1cm
10%multiple
1015%malignant
10%hyperplasiaornesidioblastosis

Presentswithsympatheticnervoussystemsymptomsduetohypoglycemia(patientslooklikePillsbury
DoughBoy)

WhipplesTriad:
1.Hypoglycemia<50mg/dl
2.CNSsymptoms.
3.ReversalofCNSsymptoms.withglucoseadmin.

Ddxforhyperinsulinemia:
Reactivehypoglycemia(verycommon),
Functionalhypoglycemiawithgastrectomy,
Adrenalinsufficiency,hypopituitarism,hepaticinsufficiency,
Munchausenssyndrome(selfinjection)
Tumorssecretinginsulinlikemolecule(sarcoma,mesothelioma,etc.)

First,checkforproinsulin,then:
Get72hourfastinglevelswithq6hourchecksuntilpatientbecomessymptomatic

Insulin:Glucoseratio=insulin(uU/ml)/glucose(mg/dl)>0.3foundinalmostallpatientswithinsulinoma.

AccuracyincreasedbyAmendedratio=insulin(uU/ml)/[glucose(mg/dl)30]>0.3

LocalizingTests:
CT,Agram,endoscopicultrasound,venouscatheterization(samplebloodalongportalandsplenic
veins)
Calciumangiogram:Ca
++
causesinsulinsecretionlocalizetoartery(e.g.splenicfortail)where
tumornearest
IntraoperativeU/Sisprobablythebesttestforlocalization

MedicalTreatment:
Diazoxidetosuppressinsulinlevels(untilresection).Diazoxideinhibitsthesulfonylureareceptor1
(SUR1)onthebetacell,whichisacomponentoftheK
+
ATPaseresponsibleforinsulinsecretion
Octreotide,IVglucose

HopkinsGeneralSurgeryManual 24
AdrenalGland

Embryology:
Cortex:mesoderm(4
th
to6
th
week)
Medulla:ectoderm/neuralcrest(sympatheticNSandganglion);migratesalongsympatheticchain
Ectopiclocation:IMA,OrganofZuckerkandl
Rightgland:drainsintoIVC;Leftgland:drainsintorenalvein

AldosteroneisproducedexclusivelyintheZGbecauseofthepresenceofcorticosterone
methyloxidase(anatomicallyspecificenzymelocation)
PNMTconvertsnorepinephrineepinephrine.Foundonlyinadrenalmedulla.
RatelimitingstepisTyrosineDOPAviaTyrosinasehydroxylase
11hydroxysteroiddehydrogenasetypeIisrequiredtoconvertinactiveprednisonetoactive
prednisolone;itsactivityvariesmarkedlyfrompersontoperson
Cortisolisnotastoragehormone;however,itdoespromotegluconeogenesistopreservehepatic
reserve

Regardlessofsize,anadrenalmassshouldberemovedifitis:
1.Growing,
2.Functioning,or
3.SuspiciousonT2MRI(thebrighteritis,themoresuspiciousitis)
Ifnoneoftheabove,removelesionsgreaterthan46cm(since15%chanceofmalignancyifgreaterthan6
cmriskincreaseswithsize)
Ask:isitFunctional?Malignanttumorofadrenalgland?Likelymetastatictoadrenalgland?
[FigureadaptedfromRUSHreviewmanual,2000]
HopkinsGeneralSurgeryManual 25
Syndromes:
I. Conns( aldosterone):75%unilateraladenomaRx:withresection
25%bilateralhyperplasiaRx:spironolactone+C
++
channelblocker
II. Addisons( aldosteroneandcortisol):lowNa
+
,highK
+
,hypoglycemia;canpresentincrisiswith
hypotension

III. WaterhouseFriedrickson:adrenalhemorrhagewithmeningococcalsepsis

IV. Nelson:postadrenalectomy(10%)ACTH,pigmentation,changeinvisionfrompituitary
response

V. CushingsDisease(pituitary):80%ofnoniatrogeniccauses;pituitarymicroadenomaACTH
(willalsosee urine17OHprogesterone)
AdrenalCushingsSyndrome:(akaACTHindependentCushings)15%ofnoniatrogeniccauses
10%adrenaladenoma,5%adrenalcarcinoma;bilateralhyperplasiaisveryrare;willseeACTH
EctopicCushingsSyndrome:20%ofACTHdependent;sourcesofectopicACTHincluding:
Pulmonary(SCLC,bronchial,thymiccarcinoids),Neuroendocrinetumors,Pheochromocytoma,
MTC

Diagnosis:
1. Startwith24hoururinefreecortisolandplasmaACTH
2. Lowdosedexamethasonesuppressionwillsuppresscausesofhypercortisolismsuchasobesity
andexcessethanolingestion,butnotothers(confirmsdx)
3. Highdosedexamethasonesuppressionwillsuppresspituitaryadenoma,butnotectopicsources
(locatescause)
4. MRI,CT,and/orpetrosalvenoussampling

Treatment:
MedicalAdrenalectomy=metyraponeandaminoglutethimide
Surgicalremovalofallfunctionaladrenalmassesisindicated,includingbilateraladrenalectomyfor
diffusediseaseinpatientsrecalcitranttomedicalmanagement

StressDoseSteroids
[Chernowetal.AnnSurg1994,219:416]

Undernormalconditions,bodyproduces30mghydrocortisoneequivalent(solucortef)/day
Underextremestressupto300mg/day
Prednisoneis4:1(tosolucortef)
SoluMedrolis5:1
Decadronis25:1

Normaladrenalsecretionis2530mgcortisol/24h
Appropriatestresstest:250mcgcosyntropin
1.inplasmacortisolby7mcg/dL,or
2.Absolutelevel>20mcg/dL

HopkinsGeneralSurgeryManual 26
Foradrenalcrisis:200mghydrocortisoneimmediately100mgq8hoursx48hoursthentaperby50%
reductionq2daysuntil25mgreached

Above50mghydrocortisone/dayyouaregettingenoughmineralocorticoidactivity(except
dexamethasone),BUTbelow50mg/daymustreplacealdosteronewithFlorinefAcetate

ProvenAdrenalInsufficiency/ChronicSteroids[givefollowinginadditiontomaintenancedoses]:

I.Mildillness/nonfebrile
noreplacement

II.Modillness(fever,minortraumaorsurgery)
15mgprednisoloneqduntil24hpostresolution

III.Severeillnessormajortraumaorsurgery
50mghydrocortisoneq6htapertonormalby50%/day

IV.SepticShock
50mghydrocortisoneq6h50mcgflorinefqdx7days

HopkinsGeneralSurgeryManual 27
Pheochromocytoma

Tumorofadrenalmedullaandsympatheticganglion(fromchromaffincelllines)producingcatecolamines
(NE>Epi)

Incidence:0.2%(1/500hypertensives)

Ruleof10s
10%malignant
10%bilateral
10%inkids
10%multipletumors
10%extraadrenal

FoundinMENII(AandB)alwaysruleoutMENwithdxofpheochromocytoma

ClassicTriad
1.Palpitations
2.Headache
3.Episodicdiaphoresis
(also,50%hypertensive)

Ddx:
RenovascularHTN,menopause,migraines,carcinoidsyndrome,preeclampsia,neuroblastoma,anxiety
disorder,hyperthyroidism,insulinoma

Locations:
Adrenal(90%)
OrganofZuckerkandl(embryonicchromaffincellsaroundtheabdominalaortanearIMA;normally
atrophiesinchildhood)
Thorax
Bladder
Scrotum
(Note:ifepihigh,mustbeatornearadrenals,sincenonadrenalsiteslackabilitytomethylateNEtoepi)

Locators:
CT,MRI,
131
IMIBG(anNEanalogthatcollectsinadrenergicvesicles)

Note:Histologycantdeterminemalignancy;onlyspreadcan

PreopTreatment:
Increaseintravascularvolume
Mustgiveblockers(phenoxybenzamineorprazosin)for57dayspriortosurgerytocontrol
HTN.If,afterBPcontrolled,stilltachycardicaddonblockerfor2to4days.
Catastrophicerrortobeginwithblockerbecausethiswillleadtounopposedvasoconstriction
whichcancauseacuteheartfailure.

HopkinsGeneralSurgeryManual 28
PituitaryGland

Bitemporalhemianopsiaisclassicvisualchangewithpituitarymasseffect

Prolactinoma:#1pituitaryadenoma

Sheehansyndrome:postpartumlackoflactation,persistentamenorrhea

HopkinsGeneralSurgeryManual 29
ThoracicSurgery

LungCancer
170,000cases/yrinUS
#1cancerkillerinUS
5yearsurvival<15%
NSCLC[80%;adenocarcinomaseenwithincreasingfrequency(55%);doesworsethansquamous
cell(45%)],
SCLC[20%]
SquamouscellassociatedwithPTHrP;SmallcellassociatedwithACTH,ADH

Staging:
T1:3cm T2:>3cm T3:invasionofchestwall,pericardium,diaphragm,<2cmfromcarina
T4:unresectable;intomediastinum,heart,greatvessels;effusion

N1:ipsihilar N2:ipsimediastinal N3:contralateral,scalene,orsubclavian

M:2separatelesionsinsamelungM1diseaseundernewstagingsystem

StageI:T12 StageII:T2N1,T3N0 StageIIIa:uptoT3orN2

StageIIIb:unresectableT4orN3 StageIV:anyM

DdxforlungmassonCT:
HopkinsGeneralSurgeryManual 30
Associationofsmokingandlungcancer
90%oflungcanceroccursinsmokers
1420foldhigherriskinsmokers;25foldhigher(neverzero)informersmokers
Showntobeamultistepprocess[NEJM265:253]offieldcancerization;moresmokingmoreCIS
onautopsy
3p14lossofheterozygosity88%smokers;45%formers;0%nonsmokers

Riskofsurgery:
PrethoracotomyPFTs:needFEV1>2L,1Lforpneumonectomy/lobectmy
WantPostopFEV1>8001000mL(40%predicted)
DLCO<60%significantrisk;MVO2<10mL/kg/minsignificantrisk

StageIIIdisease:
1.ConfirmN2status(FNA,mediastinoscopy,VATS)
2.CDDP/EtoposideorTaxol/CDDP+surgery+XRT

Severalstudies[RosellNEJM94,RothJNCI94+followups]couldendtheroleofsurgeryinIIIAdisease.Showed
thatwithinductionchemo+XRTsurgeryhadequalsurvivalwithsignificantlymoredeathsinsurgery
arm,butcurrentlystageIIIApatientsundergosurgicalresection

LymphNodeStations[MountainCF,etal.Chest,1997]:

Mediastinoscopycansamplestations1,2,4,and7(R10ifaggressive)
HopkinsGeneralSurgeryManual 31
PancoastTumor:involvessympatheticchain(Hornerssyndrome);shoulder/medialscapulapainismost
commonpresentation;MediastinoscopyinductionchemoradicalresectionXRT

Significantlyhigherincidenceofrightsidednodeinvolvementwithleftsidedlungtumorsbecauseof
lymphaticpathwayswhichtravelfromleftright;thereverseinnotobserved

Metastatictumors(lung,breast)topleura>>primarypleuraltumor(mesothelioma)

InSummary:
1.SurgeryisstillstandardofcareforI,II,selectedIIIA,andselectedIIIBNSCLC(andveryrareIVdisease,
e.g.isolatedbrainoradrenalN0disease)
2.XRTimproveslocalcontrol,butnotsurvival
3.AdjuvantRTfor>T2,N12disease
4.InductionchemoisprovenforstageIIIdisease,butisuntestedforearlydisease.

Seeexcellentreview:MultidisciplinaryManagementofLungCancer[Spiraetal.NEJM350;379,2004]

Factorsthatairleakafterresection:
1.Neoadjuvantchemo/radiation
2.Deepdissection
3.Blebs/emphysema

Massivehemoptysis:>600mLin24hours

Spontaneouspneumothorax:usuallyresultofrupturedsmallbleb;1520%ofrecurrenceafterinitialevent
(muchgreaterafter2
nd
event)

ChyleLeak:
Thoracicductenterschestonright(withaorta)crossestoleftatT4/5joinsatIJ/subclavian
junctiononleft
Mostofteniatrogenic
Normalchyleflowvariesbetween1.5and2.5L/dayaccordingtodiet
Highlymphocytes(makingitresistanttoinfection)and10xTGofserum
Treatwith2weektrialofNPOanddrainage(5070%success);ifstill>500mL/daytoORfor
ductligation

Empyema:exudative(thin,freeflowingfluid)fibrinopurulent(fibrindeposition,beginningtoloculate)
organizing(ingrowthoffibroblasts,peel)

ExudativeStage:mayrespondtoantibiotics
drainage
FibrinopurulentStage:requireschesttube
surgery
Thin
WBC<1000/mm
3

LDH<5001000IU(pleuralfluid/serum>0.6)
Pleuralfluid/serumprotein>0.5
pH>7.30
Glucose>60mg/dL

Turbid,bacterialcellulardebris
Glucose<40mg/dL
LDU>1000IU
WBC>5000/mm
3

pH<7.10
HopkinsGeneralSurgeryManual 32
MediastinalDisease

Division Contents Tumors

Anterior(and
Superior)
1. Aorticarchandthoracicportionsofits
branches(brachiocephalic,leftcommon
carotid,leftsubclavian)
2. Brachiocephalicveins,upperhalfofSVC
3. Vagusnerves,leftrecurrentlaryngeal
nerve,phrenicnerves
4. Superioresophagus
5. Uppertrachea
6. Thymus
7. Upperportionofthoracicduct
8. Lymphnodes
Thymoma
Germcelltumor
Lymphoma
Thyroidadenoma
Parathyroidadenoma
Lipoma
Carcinoma
Hemangioma
Middle 1. Pericardium
2. Heart
3. Trachealbifurcationandmainstembronchi
4. Subcarinalandperibronchialnodes
5. Ascendingaorta
Bronchogeniccysts
Pericardialcysts
Lymphoma
Posterior 1. Thoracicportionofdescendingaorta
2. Azygos,hemiazygos,accessory
hemiazygosveins
3. Sympatheticchains
4. Thoracicduct
5. Esophagus
Neurogenictumors
Lymphoma
Entericcysts
Mostcommoninbold

HopkinsGeneralSurgeryManual 33
RoleofthymomaandMyastheniaGravis:

ResectingthymusinMG,eveninabsenceofthymoma,improvessymptomsin90%,asthymushas
beenimplicatedinproducingpostsynapticantiAchantibodies
Completeremissionmostlikelyif:age<60andoperationperformed<8monthsfromdiagnosis
Radiatethymomaafterexcisiononlyifmarginspositiveandconsiderplatinumbased
chemotherapy.
Invasivenessattimeofresectionbestpredictsoutcome

Otherdiseasesassociatedwiththymoma:
EatonLambertsyndrome
Sjgrenssyndrome
Redcellhypoplasiaandaplasia

DiagnosticworkupofMediastinalMasses

Location Mass Test

Superior Thyroid ThyroidScan

Anterior Thymoma Resection

Germcell HCG,AFT
Lymphoma Openbiopsy

Posterior Neurogenic MRI

HopkinsGeneralSurgeryManual 34
CardiacSurgery:CongenitalDefects

VentricularSeptalDefect(VSD)
MostcommonCHD(25%,1/1000livebirths)
Multipletypes:perimembranousismostcommon
Upto50%haveassociatedanomaly(PDA,coarctation,AS)
PVRovertimebecauseofpulmonaryovercirculation,andmybeirreversibleat2years
MaygoondevelopEisenmengerssyndromewithshuntreversalacrosstheVSD
Fixifshuntfraction(Qp/Qs)>2(twicebloodflowtolungs)
RepairunrestrictiveVSDpriorto1yearofage(preventfailuretothrive)

PatentDuctusAteriosis(PDA)
Communicationbetweenupperdescendingaortaandleft/mainPA
Presentationdependantondegreeofleftrightshunt(pulmonaryovercirculationandstealfrom
systemicperfusion)
PersistentPDAismorecommoninprematureinfants
Medicalclosure:indomethacin(uptothreedoses)
Longtermcomplicationofpulmonaryovercirculationinclude:pulmonaryHTN,CHF,increased
respiratoryinfections
Earlysurgicalclosureindicatedforsymptomaticpatientswhoarerecalcitranttomedicaltherapy,or
arenotsuitablecandidatesformedicaltherapy
Useprostaglandintokeepopenincyanoticinfants;canalsocloseincathlab

Acyanosis
Echo,SaO2andCath
todistinguish
between:
Central
Cyanosis
NormaltoPulmonaryBloodFlow
1. Coarctationofaorta
2. Pulmonicstenosis
3. Aorticstenosis
4. Anomalousoriginofleft
coronaryarteryfromPA
(ALCPA)

Normalto Pulmonary
BloodFlow
1. TranspositionofGA
2. Hypoplasticleftheart
syndrome
3. Singleventricle
4. Truncusarteriosis
5. Totalanomalous
pulmonaryvenous
return
NormaltoPulmonary
BloodFlow
1. TetralogyofFallot
2. Tricuspidatresia
3. Pulmonicatresia
4. Ebsteinsanomaly


PulmonaryBloodFlow
1. VSD
2. ASD
3. PDA
4. Aortopulmonarywindow
5. Endocardialcushiondefect(AV
canal)
6. Cortriatriatum
[FigureadaptedfromGeneralSurgeryBoardReview,Goldetal,1999]
HopkinsGeneralSurgeryManual 35
CoarctationoftheAorta
Accountsfor68%ofCHD(25xmorecommoninmales)
Theusuallocationofthediscretecoarctationisjuxtaductal(justdistaltotheleftsubclavianartery)
Lessoften,thecoarctationisjustproximaltotheleftsubclavianartery;canalsobediffuse
Twotheories:
1.Reducedantegradeintrauterinebloodflow,whichcausesunderdevelopmentoftheaortic
arch
2.Extensionoftheductaltissueintothethoracicaortawhich,whenitconstricts,causes
coarctationoftheaorta
Themostcommonclinicalmanifestationisadifferenceinsystolicpressurebetweentheupperand
lowerextremities(diastolicpressuresareusuallysimilar),manifestedby:
1.Upperextremityhypertension
2.Absent/delayedfemoralpulses
3.Low/unobtainablebloodpressureinthelowerextremities
Treatmentoptionsincludeangioplastystenting(if>25kg)orsurgicalrepair(resection+endto
endspatulatedanastomosis,bypassifsegmenttoolongforprimaryrepair)

AtrialSeptalDefect(ASD)
Strictlyspeaking,aPatentForamenOvale(PFO)onlyshuts:rightleft
UsuallyanASDshunts:leftright
Accountsfor1015%ofCHD(mostcommononeinadults)
SecundumdefectismostcommonASD(PFOismorecommon)
Spontaneousclosurerare>2yearsofage
Typicallyasymptomaticwithmurmur;5060%haveeasyfatigability
FixalmostallpersistentASDs
Canbeclosedviacatheterization

TetralogyofFallot
Fouranatomicfeatures(keyisRVOTobstruction):
1. StenosisofPA
2. RVhypertrophy
3. VSD(usuallysingle,large,andunrestricted;intheperimembranousregionoftheseptum)
4. AortaoverridingtheVSD
Accountsfor710%ofallcongenitalheartdisease(3.3per10,000livebirths)
Approximately15%ofchildrenhaveextracardiacanomalies(e.g.trisomy21)
PhysiologyandclinicalpresentationoftetralogyisdeterminedprimarilybytheextentofRV
outflowobstruction.Mostchildrenarecyanoticandsymptomatic.
Severeobstructionwithpoorpulmonaryflow:profoundcyanosisduringnewbornperiod
Moderateobstructionwithbalancedpulmonaryandsystemicflow:maybeidentifiedduring
electiveworkupforamurmur
Minimalobstruction:pulmonaryovercirculationandlateheartfailure
Optionsforrepairinclude:
PatchrepairoftheRVOT,possiblyrenderingthepulmonaryvalveincompetent,which,ifsevere,
mayhavesignificantlongtermhemodynamicandelectrophysiologicconsequences.
AnalternateprocedureistheinsertionofavalvedconduitfromtheRVtothedistalmain
pulmonaryarteryifthereispulmonaryatresiaoracoronaryanomalyprecludingatransanular
incision
HopkinsGeneralSurgeryManual 36
CardiacSurgery:AcquiredDefects

4buzzwordstodescribecardiacphysiology
Inotropy:forceofcontraction(systolic)
Chronotropy:rateofcontraction
Lusitropy:rateofrelaxation(diastolic)
Dromotropy:conduction

CoronaryArteryBypassisassociatedwithimprovedsurvivalinpatientswith
triplevesseldisease
leftmaindisease
patientswithEF
i.e.themoreextensivediseasethegreaterthebenefit

Indications:
Intractablesymptoms,medicallyrefractory
>50%leftmaindisease
TriplevesseldiseasewithdepressedEF
LeftdominantcirculationwithhighgradeLADstenosis

Dominance:85%arerightdominant,whichmeansRCAsupplies:
1. PDA
2. AVnode
3. Posteriorcruxofheart(nearIVC)

Branchesofmaincardiacvessels
1. Leftcircumflex:obtusemarginals
2. Leftanteriordescending:diagonalsandseptals
3. Rightcoronary:acutemarginalbranches;ifrightdominant:PDA,AVnodal;septals

Saphenousveinpatency5060%at10years
IMApatency95%at10years
RateofrecurrenceofanginafollowingCABis57%peryear

IABP
Positionedjustdistaltoleftsubclavianartery(aorticknobonCXR)
Inflatesduringdiastole(40msecbeforeTwave;afterload)anddeflateswithpwave(coronary
perfusion);AIisacontraindication

AcuteMIComplications

1.Arrhythmias:PVC,ventricularectopy,
VT/VF,PEA(pulselesselectricalactivity)(048hours)
ReperfusioncancausePVCs

2.Recurrence:(07days)

3.PericardialDisease*:pericarditis;Dresslerssyndrome(pericarditis+effusion)(6hours14days);likely
autoimmune inflammationofpericardium;pleuriticchestpain,lowgradefever,malaise;treatwith
steroidsorNSAIDs;
*keyistodifferentiatefrommediastinitis

HopkinsGeneralSurgeryManual 37
4.Mediastinitis:follows13%ofcardiacsurgery;risksinclude:DM,age>60,reexplorationforbleeding,
steroids,obesitywithbilateralIMAharvest;needreoperativedrainageandflap(advancementpec,or
transfer)

5.StructuralCatastrophes(35days)
a)papillarymuscletear;usuallyfollowsposteriorMI:acuteMRpulmonaryedema
b)septalrupture:VSD(SOB)
c)freewallrupture:rapiddeath

6.Aneurysmformation(weeks);10%ofpatientspostMI;usuallyafteranterolateralinfarctcausedby
proximalLADocclusion(anteriorandapical);candevelopprogressiveLVfailurewithCHF;nidusfor
emboliandarrhythmia;surgicalinterventionifsymptomatic

7.CHF+Recurrence:ANYTIME

Mitralstenosis
Symptoms:CHF,pulmonaryedema,rightsidedheartfailure,AFib,embolization
Etiology:RF
Normalmitralarea=45cm
2
;usuallysymptomsdevelopwhenareafallsbelow1.4cm
2

Physiology:LApressureCOPVR
Surgeryindicatedfor:Area<1cm
2
,CHF,pulmonaryHTN,embolization,gradient>5mmHg

Mitralregurgitation
Symptoms:CHF
Etiology:myocardialischemia/infarct,endocarditis(acute);MVP,RF,myxomatousdegeneration(chronic)
Physiology:abnormalityofannulus(dilatation),leaflets(redundancy[prolapse],defect[endocarditis],
shrinkage[RF]),chordaetendineaerupture,papillarymusclerupture
Surgeryindicatedfor:acuteMRcomplicatedbyCHForshock,endocarditisassociatedwithshockor
persistentsepsis/embolization,EF<55%,EDdimensions75mm,ESdimensions45mm

MitralStenosis MitralRegurgitation
AlmostexclusivelycausedbyRF
PulmHTNandRHfailureseen
Afibandembolizationcommon

RFiscommoncause,butalsoendocarditis,MVP,ruptured
chordaetendineae,myxomatousdegeneration
PulmHTNandRHfailurealsoseen
Embolizationlesscommon;LVfailuremorecommon
OperateforLVchambersize(LVESV>55),heartfailure,
newAfib.
Earlieroperation=chanceforsuccessfulrepair

Aorticstenosis
Symptoms:Angina,SOB,syncope
Etiology:RF,bicuspidvalve,degenerative(ingeneral:<50congenital,5070bicuspid,>70
calcific)
Avoidpreloadreduction,avoidhypotensionandACEinhibitors
Slowcarotidupstroke,softS2
Criticalstenosis<0.8cm
2

TypicallyCXRshowsnormalsizeheart(ruleofthumb:stenosisnormalsizeheart;regurgitation:
dilation)

HopkinsGeneralSurgeryManual 38
Prognosisdependsonsymptoms:
1.CHFworstprognosis(1.5years*);occursatapproximately0.70.8cm
2

2.Syncopepostexertional(3years*)
3.Angina(5years*)
*Meansurvivalfrominitiationofsymptoms

needantibioticprophylaxis
criticalASdiagnosedbysymptoms,notarea
symptomsneedsurgery,goodoutcomeevenin80s
averageprogression0.12cm
2
/year

Surgeryindicatedfor:Area<0.81.0cm
2
,gradient>50mmHg,symptoms,evidenceofrapidcardiac
enlargement

Aorticregurgitation(AR/AI)

3Fs:Fast(mustbekepttachy),Forward(reduceAL),Full(preloaddependent)

Symptoms:Fatigue,angina,progressivedyspnea,palpitations,peripheralvasomotorchanges;bounding
peripheralpulses(widepulsepressure)
ESLVdiametergreaterthan5cmhasincreaseddeathrate(19%vs.5%peryear)
AcuteRx:afterloadreduction,diureticsforCHF
Surgery:symptoms,evidenceofventricularenlargement

PerioperativeMI

Mostlikely23dayspostop
DifferentiateAcuteMIfromAcuteCoronarySyndrome
A. AcuteMI:CP,STelevations,+enzymes
Goalsare:1.Reperfusion(fibrinolytic06hours;cath),and2.DecreaseO2demand

B. AcuteCoronarySyndromeissubdividedintoNonQwaveMIandUnstableAngina(CP,withno
EKGchangesorenzymes)
NonQwaveMI:CP,EKGchangeswithoutSTelevation,+enzymes;giveMONA(MSO4,O2,nitrate,
ASA)+blockerthenIIb/IIIa+heparin

*Note:InferiorinfarctRCA90%chanceofAVnodalinvolvement2:1blockmorelikelytobeMobitz
I>IIgiveatropine

HopkinsGeneralSurgeryManual 39
CXRappearancewithcardiachypertrophy/enlargement

(Blackoutlineisnormalcardiacsilhouette)

LVH RVEnlargement RAEnlargement LAEnlargement

Arrhythmias

ThreeRulesofThumb:
1.Ifpatientishemodynamicallyunstableasaresultofdysrhythmiaproceeddirectlytocardioversion
(300J)
2.Ifpatienthasawidecomplextachycardiaproceeddirectlytocardioversion(300J)
3.Ifthepatienthasanarrowcomplextachycardiainfuseadenosine(orverapamil)fordiagnosis
(Amiodaroneisbecomingdrugofchoicefortreatment)

Adenosineisanendogenousnucleosidewithdifferentialantidysrhythmiceffectsonbothsupraand
ventriculartissue;alsodepressestheautomaticityofboththeSAandAVnode.
Twotypesofadenosinereceptorsinheart:
A1(onAVnodeandmyocytespromotingAVblockandbradycardic),and
A2(onvascularendothelialsmoothmusclemediatescoronaryvasodilation)

EaglesCriteria:Riskofsurgery(Morethan2warrantcardiologyworkuppriortosurgery)

I.Symptomatic
CHF
Angina

II.Demographic
DM
male
age>70

III.EKG
Qwavespresent
ventarrhythmia

Preopexercisetoleranceisthemostsensitiveindicatorofabilitytowithstandsurgery.Ifpatientunableto
walk2flightsofstairsproblemslikely
HopkinsGeneralSurgeryManual 40

Criteriaforuseofperioperataive
blockade
RevisedCardiacRiskIndexCriteria
(3preopworkup)
Age>65*
Hypertension
Currentsmoker
Cholesterol>240mg/dL
NIDDM
Highriskprocedure(intraperitoneal,
intrathoracic,suprainguinalvascular)
Ischemicheartdisease
HistoryofMI
Historyofangina
UseofSLnitroglycerin
Positiveexercisetest
QwavesonEKG
PreviousPTCA/CABwithischemicchestpain
Cerebrovasculardisease
HistoryofTIA/CVA
IDDM
CRI(Cr>2mg/dL)

*Manywoulduseblockadeforpatients>40

AtrialFibrillation

RateControlvs.RhythmControl:2largestudies[NEJM2002,347:18251833,18341840]evaluatedpatients
withatrialfibrillationforlessthan1yeardeemedtobeathighriskforrecurrence.Thesestudies
concluded:

1. Ratecontrolwasnotinferiortorhythmcontrolforthepreventionofdeathandmorbidityfrom
cardiovascularcausesandmaybeappropriatetherapyinpatientswithrecurrenceofpersistentAfib
afterelectricalcardioversion.
2. ManagementofAfibwithrhythmcontroloffersnosurvivaladvantageovertheratecontrol
strategy.Anticoagulationshouldbecontinuedinthesepatients.

Hence,bothrateandrhythmcontrolledpatientsneedanticoagulationastheirstrokerateis1%peryear.

HopkinsGeneralSurgeryManual 41
SurgicalApproaches:

[NittaT,etal.AnnThorSurg199967:27]
Radiofrequencyablation,cryoablationpossibleinterventionsforchronicAfib(RFAisbecoming
popularbecauseofthecomplexityoftheMazeprocedure).
ElectricalcardioversionisrarelysuccessfulinconvertingchronicAfib.
90%ofparoxysmalAfibcuredwithpulmonaryveinisolationalone
PersistentAfibgenerallyneedfullCoxMazeIII;RFA6070%cure;Maze90%cure

HopkinsGeneralSurgeryManual 42
VascularSurgery

NitricOxide:derivedfromLarginine;reducesfreeradicals(byscavenging)andpreventsatherosclerosis;
cGMPactsasthe2
nd
messenger

Cerebralischemiamostoftencausedbyatheroembolization(50%ofstrokesduetoHTN,25%duetocarotid
disease,25%duetobleedorothercause).

ClinicalClassification
1. Asymptomatic:bruits(+bruit3050%havesignificantstenosis;+significantstenosis2050%
bruit;Bruitareactuallyasignificantpredictorofcardiacdisease)
2. TIA:<24hourresolution(90%resolvewithin2hours)
3. RIND(ReversibleIschemicNeurologicDeficit):2448hourresolution
4. Fixeddeficit:stroke

RisksofStroke:

700,000peryear 160,000deaths/year
1yearpoststroke 2/3ofsurvivorshavedisability

TIA:15%strokeinfirstyear,thenabout6%peryearthereafter(40%chanceofstrokein5yearswithout
ASA)

CorticalTIA VertebralTIA
Unilateral Dizzy
Armweakness Bilateralwoozy
Decreasedvision Dropattack(transientlossofmotortone)

Asymptomatic: Stenosis>50%:about4%peryear
Stenosis>80%:35%riskover2years
2%peryearriskofstrokeforpatients>60

CarotidStenosis

Lowresistancearterialsystems(suchasICA):totalbloodflowdoesnotdecreaseuntilstenosis>
50%.Hence,noneedtorepairstenosis<50%
Upto50%ofpatientswhosufferstrokehavehadpreviousTIA

AsymptomaticCarotidArteryStenosisTrial(ACAS)demonstratedthatpatientswithanasymptomatic
stenosisof60%orgreaterhada53%relativeriskreductionofstrokeafterundergoingCEA+ASA
comparedtoASAalone[115%].Thebenefitwasmuchgreaterinmenthanwomen.

NorthAmericanSymptomaticCarotidEndarterectomyTrial(NASCETI)demonstratedthatCEAis
highlybeneficialinpatientswithrecenthemisphericorretinalTIAornondisabalingstrokeandan
ipsilateralhighgradestenosis(7099%).Thebenefitofsurgerywasseenwithin3monthsofoperation.
Theincidenceofstrokewasdecreasedinallsubgroupsbutwaslargestinpatientswhoexperiencedmajor
ipsilateralstrokewithan81%riskreduction.Overall,26%ofpatientswithhighgrade(7099%)stenosis
sustainedastrokewithin18monthswithmedicalmanagementvs.9%withsurgeryat2years[269%]

NASCETII:lookedatsymptomaticpatientswith5069%stenosisandfoundareductionfrom2216%
(p<0.045).Morehospitalsparticipated,henceincreasedmorbidity.
HopkinsGeneralSurgeryManual 43
Diagnosis:Ask3questions(ICAdisease?%stenosis?Characteristicsofplaque?)
Neckduplexconsistsof2parts:BmodeU/Simageandspectralvelocityanalysis
IC/CCsystolicratiogives%stenosis:
<2 <50%
23.9 5069%
>4 7099%

FollowingCEA:
Ifipsilateralpreorbitalheadachethinkhyperperfusion(sincestenosisremoved);usually35
dayspostsurgery.
MostcommonCNinjuryvagusnerve(clamp)hoarseness
CNXIItonguedeviationtosideofinjury;marginalmandibularlipdroop
CADismaincauseofpostopmortality

Restenosisrate510%(>50%stenosiswithin2years:myointimalhyperplasia,notatherosclerosis;
F>M)

UpperlimitguidelinesforacceptableM&MratesforCEA:
Asymptomatic:3% Symptomatic:5% Symptomatic/CVA:7% RecurrentStenosis:10%
ToparticipateinACASandNASCETtrialscentershadtohave<5%overallmortalityforCEA

CarotidAnatomy

[AtlasofSurgicalOperations,Zollinger&Zollinger,7
th
,1993]
HopkinsGeneralSurgeryManual 44
AbdominalAorticAneurysm

95%infrarenal
approximately75%asymptomaticanddiscoveredincidentally
growthrate0.4cm/yearindiameter
riskofruptureforsmall(<5.5cm)aneurysms:0.61%peryear[NEJM2002,346:14371444,14451452]
Pathology:matrixmetalloproteaseactivity(MMP1,2,3;MMP9)
riskofrupturerelatedtosize:
<5cm:20%5yearrisk
57cm:33%
>7cm:95%
1020%involveiliacs
whenremovingdistalclamps,removeINTERNALiliacfirst,thenEXTERNALiliactoavoiddistal
embolizationtolowerextremities
followingrupturewithoperativerepair:cardiaccomplicationsaremostcommoncauseofearly
death;renalcomplicationsforlatedeath
CADismostcommoncauseofdeathforpatientswithsmallAAA(<6cm);
Rupture(7590%mortality)ismostcommoncauseofdeathforpatientswithlargeAAA(>6cm)
[unlesstheyhavemetastaticcancerordebilitatingCHF]

IndicationsforRepair:

Goodriskpatients: 1.AAA>5.5cm+lifeexpectancy>2years
2.AAA<5.5cmwithCOPD,expansion>0.5cm/6months
Highriskpatients: 1.AAA>6cm,orsymptomatic

TheUKSmallAneurysmTrial:[NEJM346(19):1445,2002]Randomlyassignedover1000patientswith
aneurysmsrangingfrom4.0to5.5cmtoeitherundergoearlyelectiverepairorobservationwithU/S
surveillance.Meanfollowupwas8years.Themeansurvivalwas6.5yearsinthesurveillancegroupvs.
6.7yearsinthetreatmentgroup(p=0.29).Earlymortalitywasgreaterinthesurgerygroup,buttotal
mortalitywasgreaterinthesurveillancegroupat8years.

IndicationsforRetroperitonealApproach:
hostileabdomen
InflammatoryAAA
juxtarenalAAA
Rightiliacdiseaseisarelativecontraindication
Benefits(vs.anteriorapproach)include:respiratoryproblems,LOS,minimalileus

HopkinsGeneralSurgeryManual 45
Optionsforocclusiveaortoiliacdisease:

40%ofaneurysmalinfectionscausedbysalmonella
Staphaureusandgramnegativebacteriaaremostcommonorganismsinearlygraftinfection;staph
epidermidisismorechronic(presents>4months;at2yearsonaverage)

AortoentericFistula(AEF):Primary(nograft)vs.Secondary(graft)
80%distalduodenum(aorticpathology>75%;GIpath15%)
causes:graftinfection,duodenaltrauma(ischemia)duringoriginaloperation,inadequategraft
coverage

SecondaryAEF:
90%aregraftentericfistula(anastomotic)vs.10%graftentericerosion(paraprosthetic)
6080%presentinitiallywithselflimitedsentinelbleed
OfallpatientswithGIbleed+historyofaorticreconstruction2%haveAEF(hence,doendoscopy
1
st
toruleoutothercausesofUGIB)
Mortality35%
Documentfemoralpulses
CTwithIVcontrast(minimumof3mmcuts)[CT>angio:showsmorethanlumen]
Angiographyif:(i)symptomaticmesentericdisease,(ii)questionofrenaldisease,(iii)nofemoral
pulses(needtoknowtargets),(iv)significantPVD/claudication
GoldStandardrepair:graftexcision,closureofaorticstump,extraanatomicrevascularization(close
duodenumprimarily)
[RUSHReviewofSurgery,2000]
HopkinsGeneralSurgeryManual 46
EndovascularStenting:

Endovascularstentgraftplacementiswidelyperformedforthetreatmentofinfrarenalabdominalaortic
aneurysms.Althoughadvancesingraftdesignhavegreatlyexpandedthepopulationofpatientswho
wouldbeconsideredcandidatesforendograftplacement,therearecertainanatomiclimitationsthatplace
thepatientathighriskforatypeIendoleak(alackof,orsuboptimalfixationin,theproximalordistal
attachmentsite).Criticalinformationthatthevascularsurgeon/interventionalistneedstoknowpriorto
embarkingonanendograftplacementprocedureincludes:

1. Isthereasufficientlengthofneck(15mm)ofnormalaortaabovetheaneurysm?
2. Isthewidthoftheneck<2026mm?
3. Whatisthedegreeofangulationoftheneck(needstobe<60
o
,seefigure)?
4. Istheinferiormesentericarterypatent?
5. Arethecommoniliacarteriesaneurysmal?
6. Arethecommoniliacarteriesaneurysmalwithrespecttothedistalaorta?
7. Arethehypogastricarteriespatent?
8. Aretheexternaliliacarteriespatent?

97%successinstallation
Nostudyshowsdecreasemortality(onlydecreasedmorbidity)
Actuallyincreasedcostwithfollowup
1%/yearrupture/explantrate
Upto50%ofpatientswilldevelopanendoleak
2030%needreinterventionwithin2years
5yearsurvival:75%(sameasopen)

Leaks(I,IIIareworst)
I. Presumedanastomosissite(fixedsiteleak)mustbefixedwhendiagnosed
II. Graftleakviacollaterals(branchvesselleak;backbleeding,usuallylumbars)mustbefixed
orconvertedtoopenifcontinuestoexpand*
III. Tearingraft(graftdefect)
IV. Transgraftegression(needleholes/porosity):selflimiting
V. Endotension(controversial):saidtooccurwhenthereisintrasacpressurewithoutevidence
ofendoleak.Unsureofcause.

*TypeIImyclosespontaneouslywithinfirst12months;hence,ifaneurysmsacnotexpandingwarrants
observationfor12months.Repairifsacpersists>12monthsORsacinsize.

PresentlyOVER(OpenVs.EndovascularRepairofAAA)Trialhasrandomized>400patients
[FiguretakenfromtalkgivenbyLesCunningham,2005]
HopkinsGeneralSurgeryManual 47
PeripheralVascularDisease

Claudication:
Historyiskey:Reproduciblepainofbuttock,thighand/orcalfassociatedwithambulationand
relievedbyrest.
Initialtreatmentissmokingcessation,exercise;Pletal>Trental(butcost);notsurgery
Thesepatientshavethesameriskofdeathfromcardiovasculardiseaseaspatientswithknown
cardiacdisease(50%diewithin5years)
Progressestogangrene23%annually(only10%everloseleg)

Restpain/ulcersindicationforbypass

Clinicalmanifestationsofcriticallimbischemia(accordingtoEuropeanConsensusConference):
1.Restpainrequiringanalgesiaforatleast2weeks
2.Anklesystolicpressure<50mmHg(withorwithouttissueloss/gangrene)

ExerciseTestpositiveif>20%fallinanklesystolicpressurerequiring>3mintorecover

ArterialFlowistriphasic:1.Forward,2.Reverse,3.Lateforward(Note:willbenormallymonophasicin
lowresistancesystem,likeICA)

ABIValues:
Calcified(diabetic)>1.2;normal>1;Claudication0.50.99;Restpain0.3
*RequireABI>0.5tohealalowerextremityamputation

1yearsurvivalafteramputationforischemicdiseaseis75%
2yearsurvivalafteramputationforischemicdiseaseis60%
3yearsurvivalafteramputationforischemicdiseaseis50%
4yearsurvivalafteramputationforischemicdiseaseis45%
50%ofpatientsloseotherlegwithin5yearsof1
st
amputation

*Mostcommonsiteoflowerlimbatherosclerosis:SFAinregionoftheadductorcanal(Hunterscanal)
*CardioatrialembolimostfrequentlyoccludeCFA

Reversedsaphenousveinpatency(goldstandardbelowinguinalligament):8090%at1year;75%at5
years;persistentsmokingis#1reasonforlategraftfailure(valveleafletremnantsis#1reasonduring1
st
two
years)

Fempopbypass:
#Vesselrunoff5yearpatency
370%
235%
11520%

PoplitealArteryAneurysm
Mostcommonperipheralaneurysm(70%ofall)
50%arebilateraland30%alsohaveAAA
2030%oflimblosswithdistalembolielectiverepairofall,regardlessofsize
Managementoptions:medialexploration:proximal/distalligation&bypass
acutethrombosispreopthrombolytics
endovascularrepair(notyetaccepted)

HopkinsGeneralSurgeryManual 48
TibperonealDisease(infrapop)*

1year4yearpatency
insituSVvein: 82% 68%
armvein 73% 58%(3year)
PTFE 46% 21%
PTFE+coum(2.0) 50%
PTFE+veinpat 74% 54%(5year)

*Peronealarteryisleastlikelyvesseloflowerextremitytobeoccludedbyatherosclerosis

Patch/collarreduceturbulenceincreasecomplianceatdistalanastomosisminimizetraumatoarterial
endotheliumdecreaseproliferativeresponse(intimalhyperplasia)

Belowkneerevascularizationshouldonlybeperformedforlimbsalvage(includingrestpain)

Contraindicationstothrombolytictherapy:recenthistory(6months)ofTIAorCVA;recent(10days)
operationorGIbleed;presenceofintracranialmalignancyorvascularmalformation;uncontrolled
hypertension

LowerExtremityVascularAnatomy

Anteriorview PosteriorView

[VascularSurgery,HouseOfficerSeries,3
rd
FaustandCohen,1998]
HopkinsGeneralSurgeryManual 49
EvaluatingLowerExtremityUlcers

Firstdiagnosethecause(diabetic,venousinsufficiency,arterialinsufficiency,vasculitis,IBD,etc.)

Themostcommonarediabetic,arterial,andvenousinsufficiency:

I.Diabetic:typicallyoccuronpressurepointsonthefootandarepainlesssecondarytotheacquired
neuropathy

II.ArterialInsufficiency:extremelypainful,associatedwithrestpainindistalfoot,havegrayishgranulation
tissue,surroundedbyblueandmottledskin,anddonotbleedwhendebrided.Painismostcommonover
metatarsalheads,nottoes(usuallyoccuratpressurepoints).

III.Venousinsufficiency:large,irregular,shallow,haveredgranulationtissue,occuraroundmedialand
lateralmaleoli,andaresurroundedbybrawnyedemaandstasispigmentation.Leukocytesarethoughtto
playanimportantroleinthepathophysiologybecausetheyhavebeenfoundtobesequesteredintheankle
regionofpatientswithelevatedvenouspressures,especiallyinthedependentposition.Theyplug
capillariesandbecomeactivatedandreleasetheirenzymesandsuperoxideradicals,decreasingflow,
leadingtoischemiaandulceration

Phlegmasiaalbadolens:venousclotresultsinsuchincreaseinvenouspressureedematous,swollen,
pale,cyanoticextremity;blanchedappearanceresultofedema;canimpairarterialinflow;asurgical
emergencyrequiringthrombectomycreationofAVfistula(canuseTPA)

EvaluatingLimbIschemia

Thepresentationofperipherallimbischemiadeterminesthechronicity
Acutelimbischemiais60%thromboticand40%embolic
Alwayscheckinflow(femoralpulses)
AbsentpoplitealpulsesimplySFAocclusionormultipleproximalocclusions

Whendescribingangiographiclesions/stenosesusetermslike:none,mild,moderate,severe,and
distinguishbetweendiffuseandfocal

SVSClinicalClassificationofLimbIschemia

Sensory Motor Doppler

Arterial
Doppler
Venous
Viable Normal Normal Normal Normal
Threatened
Marginal
+/toes Normal Abnormal Normal
Threatened
Immediate
Beyondtoes Mildmoderate
deficit
Abnormal Normal
Irreversible Profound Paralysis Abnormal Abnormal
Ifyouhearamonophasicdopplersignaldistinguishbetweenarterialandvenous(venouswillchangewith
sequentialcalfcompression)

Treatment

Viable: heparinfurtherworkup
Threatened(Marginal): heparinfurtherworkup
Threatened(Immediate): heparintoORforintraopangiogram+/intervention
Irreversible: toORamputation
dose:bolus80units/kgfollowedbydripof18units/kg
HopkinsGeneralSurgeryManual 50
ThoracoabdominalAneurysms

Themostcommoncauseofascendinganeurysmaldiseaseiscysticmedialnecrosis(seeninMarfans
syndrome);allotherareasofaneurysm(includingtransversearch)aremostassociatedwithatherosclerotic
disease.
Operateifsymptomaticor>6cm

[AnnThorSurg2001;71:1233] [AnnSurg2004;240:677]

Riskofparaplegia:greatestriskTypeII;I50%risk;StagedRepairtoTAAwithelephanttrunk
III25%risk;IV10%risk

AorticDissection

StanfordA:involvesaorticarch[includedDeBakeyI(ascendinganddescending)andDeBakeyII
(ascendingonly)].Asurgicalemergency,1%mortalityperhour.

StanfordB:involvesdescendingaortaonly[sameasDeBakeyIII].Medicalmanagement(i.e.controlHTN).
Operateonlyforrupture,occlusion
HopkinsGeneralSurgeryManual 51
SplancnicArteryAneurysms

Site Incidence Pathology Clinical

Presentation
Diagnosis NaturalHistory Treatment
Splenic Mostcommon;
1/1000
Atherosclerosis
F>M
60%occur
during
pregnancy
Most
asymptomatic
20%with
variable
symptoms
Often
incidental
CalcsinLUQ
CT
Arteriography
isgoldstd
Unclear;if
symptomatic,
enlargingfix
Pregnantfix
>23cmfix
Somesayokto
watchif
1.Asympt+>60
2.calc+<1.5cm
Ifdistal
splenectomy
Ifproximal
ligateatboth
ends(noneedto
reconstruct
becauseofshort
gastrics)
Hepatic 2
nd
most
common
splancnic
Infectiousmost
common;
Mycotic
following
sepsis(e.g.
bacterial
endocarditis);
Approx80%
outsideofliver
Most
symptomatic;
PersistentRUQ
pain
Rarepreop;
Selective
celiac
Arteriography
isgoldstd
Unknown,but
rupture
devastating,so
fixallunless
serious
contraindication
ProximaltoGDA

aneurysmectomy
andligate
(retrogradeGDA
flow)
Maydosamefor
PHA,LHA,or
RHA,butrecon
withsaphenous
veinisbest
SMA 3
rd
most
common
splancnic
Rarely
atherosclerotic;
>50%mycotic
(2
o
toSBE)
Almostalways
cause
symptoms;
Intermittentor
constant
epigastric/back
pain
Epigastric
pain,tender
NONFIXED
pulsitilemass
Spontaneous
ruptureoccursin
over50%;
Operation
always
warranted
Aneursymectomy
+bypass(vein
preferredbecause
ofinfection);
Dacron
acceptable
Celiac Rare;1/8000 Atherosclerosis;
Infectious,also
Usually
asymptomatic
Usually
incidental
Unknown;
probablyhigh
riskofrupture
Aneurysmectomy
witharterial
reconstructionis
desired;
Greatestriskis
intestinal
ischemia
HopkinsGeneralSurgeryManual 52
ThoracicOutletSyndrome:anatomiccompressionofbrachialplexus,subclavian/axillaryartery,and/or
vein.

Mostpatients(95%)havepainorparesthesias
MostcommonlyintheC8toT1(ulnar)distribution[nerveconductiontestsdemonstrateslower
conductionvelocityacrossthoracicoutlet:meanof>80m/sinnormalsvs.<60m/sinaffected]
Canalsocauseatrophyofinterosseousmuscles
Arterialinvolvement:canseedistalischemia(similartoRaynaudsyndrome),1%
Venousinvolvement:extremityedema,effortthrombosisorPagetSchroettersyndrome,4%
Inexaminingthepatienttrytoreproducethesymptomswitharmelevation(EASTElevate
Arm,StressTest:putbotharmsupandpinchfingersshouldbeabletofor3minutes).
Conservativemanagementappropriateformost
Generally,thetransaxillaryapproachisbestforoperativecorrection
Fornervecompression:1
st
ribresection,anteriorscalenectomy,resectionofcostoclavicular
ligament,andneurolysisofC7,C8,T1
Forarterialcompression(producingthrombosis):1
st
ribresection,thrombectomy,embolectomy,
arterialrepairorreplacement
Forvenouscompression(producingthrombosis):viaantecubitalcatheterobtainvenogram,
performthrombolytictherapy;afterclotlysis1
st
ribresection+othercompressiveelements.Do
venogram2weekslateras50%willrequireballoondilatationofstenosisinvein

Subclavianstenosis:
Canresultinsubclaviansteal,whereuseofarmstealsbloodfromcerebralcirculationvia
vertebralarteryorarmclaudication
Bestpatencyresultsseenwithcarotidsubclavianbypassorballoondilatation

Fascialcompartmentsoflowerleg(right):

Fasciotomyshouldbeperformedconcomitantlyonthelimbifithasbeensubjectedto>48hoursof
ischemia(includingheparinizedpatients),and/orinpatientswithsymptoms
HopkinsGeneralSurgeryManual 53
VisceralIschemia

Celiac&SMAcollateralizeviaGDA,PDA
SMA&IMAcollateralizeviamarginalarteryofDrummond(arcofRiolan)

Incidence(%) Age Priorsymptoms Riskfactors Mortality

ArterialEmboli 50 Elderly Possibly
intestinalangina
Systemicatherosclerosisandthe
risksthataccompanyit;Afib
VeryHigh
ArterialThrombosis 25 Elderly Usuallynone RecentMI,CHF,arrhythmias,Rh
fever
High
Nonocclusive(low
flow)
20 Elderly Usuallynone Shock,CPB,vasopressors,sepsis,
burn,pancreatitis;digoxincan
exacerbate;treatunderlying
condition;ORforgangrenous
bowel
Highest
VenousThrombosis 5 Younger Possibleprevious
thrombosis;
DxbyCT
Hypercoagulablestate,portal
HTN,inflammatorystates,prior
surgery,trauma;treatwith
immediateanticoagulation
Lowest
mostcommonlylodgeatmajorbranchpointsalongSMA,distaltomiddlecolic
mostcommonlyoccludeproximalSMA
tendstobemoreperipheralthanarterialocclusionshortersegmentsinvolved

*Bariumstudiesarecontraindicatedbecauseoftheintraluminalpressuregeneratedandthepotentialofthebariumto
obscurefutureangiographicstudies

ChronicMesentericIschemia:typicallyneed2/3vesselsoccluded.Preferredrepairisantegrade(aorto
mesenteric)bypasswithveinorprosthetic,typicallytoasinglevessel(SMA).Candilateandstent
(especiallyifolderand/ormalnourished)
[GeneralSurgeryBoardReview,1998]
HopkinsGeneralSurgeryManual 54
Urology

1.BladderBody:cholinergiccontractsempties
2.BladderNeck:adrenergiccontractsinternalsphincterretains

Testicularmass:biopsyisorchiectomyviainguinalincision(nevertransscrotal)

Testiculartorsionbilateralorchiopexy

Ureteralinjury:useabsorbablesuture,stent,anddrain(debrideandspatulateendsoverstent)
Treatmentbasedonlocation(upper,middle,lower);middlehasworstbloodsupplyhardesttoheal

Varicoceleseenmoreoftenonleftside:leftgonadalveinleftrenalvein;rightgonadalveinIVC
Rightvaricocoelepresent,ruleoutrightrenalmasswithIVCthrombus

Seminoma
2035yearsold;Anaplasticsubtypeismostmalignant;hCGin5to10%ofpureseminoma
patients
25%haveoccultmetsinstageI
Veryradiosensitive(allstagesgetRT)
Node+disease(N1andN2)getsRT
Bulkynode+disease>5cm(N3)getsplatinumchemo(BEP)ifresidualnodes,thensurgery,if
residualnodes+fortumor,salvagechemowithVIP(vinblastine,ifosfamide,cisplatinum)

Nonseminomagermcelltumors(choricocarcinoma,embryonalcell,yolksac,teratocarcinoma)
MayhavehCGANDAFP
AFPnotelevatedinpurechoriocarcinomaorseminoma
GetLNdissection;chemoifadvanced;NOTradiation
ChemoisBEP:bleomycin,etoposide,cisplatin;pulmonaryfibrosisismostfearedcomplicationdue
tobleomycin

Lymphaticdrainageoftestes(ifcrossoverdrainageoccurs,itisrighttoleft):
Right:interaortocavalnodes&rightrenalhilum
Left:paraaortic&leftrenalhilum
[FiguretakenfromatalkbyPeterPinto,2004]
HopkinsGeneralSurgeryManual 55
Prostatecancermostoftenarisesinperipheryofgland(peripheralzone);BPHarisesincenterofgland
(transitionalzone);Prostatemetstoboneareosteoblastic(50%),osteolytic(10%)mixed(40%)and
radiodense

95%ofEPOmadebykidney;stimulatedbyhypoxia

OrthopedicSurgery

Discherniationandassociatednerverootcompression:

Disc Nerveroot
compression
Symptoms
L3L4 L4 Weakkneejerk;medialfootsensation
L4L5 L5 Weakdorsiflexion;weakbigtoe;sensationbetween1
st
and2
nd
webspace
L5S1 S1 Weakplantarflexion;weakanklejerk;sensationtolateralcalf/foot

HipDislocation

90%posteriorinternalrotation+flexed+adductedthigh
Riskofsciaticnerveinjury,AVNoffemoralhead

TibialandCalcaneousfracture:pronetocompartmentsyndrome

HumerusFracture:mayseeradialnerveinjury(weakwristextension;insensationoverlateral/dorsal
hand)

ShoulderDislocation:90%anterior;riskofaxillarynerveinjury;posteriordislocationseenwithextremely
violentmovement(seizures,electrocution)

NavicularFracture:tendersnuffboxevenwithnegativexray,requirescasttoelbow

(Closed)PosteriorKneeDislocation:Reduce1
st
,thenarteriogram;3045%incidenceofpoplitealartery
injury(intimalteardisruption)

Femurfracture
Adults:earlyORIFallowsearlymobilization,fatemboli/complications
Children:closedreductionandtoavoidinterferencewithgrowthplate

Anteriordrawersign:tearofanteriorcruciateligament(ACL)

ChanceFracture:horizontalfracturethruvertebra(body,pedicles,laminae).Seenwithsudden
decelerationwithlaponlyseatbelts;usuallyL1orL2;>50%chanceofunderlyinghollowviscousinjury
(smallbowelismostcommon)
[www.auntminne.com]
HopkinsGeneralSurgeryManual 56
GynecologicPathology

OvarianCancer
5majorclasses(basedonhistologyandembryologicetiology):
1. neoplasmsderivedfromcelomicepithelium
2. neoplasmsderivedfromgermcells
3. neoplasmsderivedfromgonadalstroma
4. neoplasmsderivedfromnonspecificmesenchyme
5. metastaticlesionstotheovary(usuallyGI,breast,oruterine)
Responsibleforhalfofallgynecologicdeathseachyear;25,000cases/yearinUS(33%5year
survival)
Allcomers:20%ofovarianneoplasmsaremalignant(withage)
Womanaged2030:10%chanceofmalignancy;50:50%chanceofmalignancy
Usuallydiagnosedinadvancedstage(2/3presentasstageIIIorIV)
CA125oflimiteduseforscreening,especiallyinpremenopausalwomen
Cytoreductivesurgeryismosteffectivetreatment(TAH+BSO;mustincludeomentum,peritoneal
washings;noneedforlymphadenectomysincetumorsspreadsbyexfoliationofcells)

UterineCancer
EndometrialcanceristhemostcommongynecologicmalignancyinUS(40,000cases/year)
75%arediagnosedasstageI,5yearsurvival>75%
Riskfactorsareassociatedwithestrogenexposure
80%ofcasesareinpostmenopausalwomen(5%inwomen<40)
Abnormalbleedingis#1presentation;histologyisadenocarcinoma>90%
TreatmentisTAH+BSO,peritonealwashings,LNsampling
Postoperativeradiation(5000radover5weeks)reservedfor:+pelvicnodes,poordifferentiation,
invasionintomyometrium,occultcervicalinvolvement
Uterinesarcomahaspoorprognosis

CervicalCancer
Most(>80%)aresquamouscell
Primarilyaffectswomenaged3545
Painlessbleedingis#1presentation(painoftensignalsadvanceddisease)
Papsmearallowsmosttobediagnosedaspremalignantlesions
HighlyassociatedwithHPVinfection(serotypes16and18virtuallyalwaysinvolved)
Treatmentforearlystage:radicalhysterectomy(noneedforoophorectomyunless>45orhas
ovarianpathology)
Chemoradiationifpoorsurgicalcandidateoradvanceddisease

HopkinsGeneralSurgeryManual 57
PostmenopausalHRTisassociatedwith:

Increasein:

Decreasein:
Endometrialcancer
Breastcancer
Venousthrombosis
Stroke
Coronaryartery
disease
Gallbladderdisease
Vasomotorsymptomsof
postmenopause
Vertebral/hip/pelvic
fractures
Osteoperosis
ColorectalCancer

Surgeryduringpregnancy:
Secondtrimesterispreferred
Bothlaparoscopicandopenproceduresduringfirsttrimesterareassociatedwithriskof
spontaneousabortionandpossibleriskofteratogenicity
Duringthethirdtrimestersurgeryisassociatedwithriskofprematurelaboranddamagetothe
uterus

Neurosurgery

DiabetesInsipiduscentralorrenal
(ADHinhibited)
SIADH
urineoutput
LowurineOsm,specificgravity
HighserumOsm,hypernatremic
urineoutput
HighurineOsm,specificgravity
LowSerumOsm,hyponatremic

PeripheralNerveInjuries
Neuropraxia:focaldemyelinationimproves
Axonotmesis:lossofaxoncontinuity(nerveandsheathintact)regeneratesat1mm/day
Neurotmesis:lossofnervecontinuitysurgeryrequiredtorepair
HopkinsGeneralSurgeryManual 58
CancerEpidemiology

HopkinsGeneralSurgeryManual 59
EsophagealDisease

4Segments:

Noserosa;mucosaisstrongestlayer
Sphinctersarecontractedatrest;NormalLEStone1525mmHg

Orderofeventsinswallowing:softpalateclosesnasopharynxlarynxuplarynxclosesUESrelaxes
pharyngealcontraction

HiatalHernia

TypeI:sliding;mostpatientswithrefluxhave,butmostpatientswithitdonthavereflux
TypeII:paraesophagealrepairevenifasymptomaticbecauseofriskofinfarction
(Also:TypeIII:esophagogastricjunctioninmediastinum,andTypeIV:entirestomachinmediastinum)

BenignEsophagealDisorders

I.Primary
Achalasia:ganglioncellsinAuerbachsplexus,absenceofperistalsis;esophagealdilation(birdsbeak
onswallow);manometryshowsnoperistalsis,highLESpressure,&failuretorelax;Rx:Botox,pneumatic
dilation,Hellermyotomy
DiffuseEsophagealSpasm:chestpain;manometryshowshighamplitudecontractions,normalLES
relaxation;Rx:Ca
++
channelblockers;iffailmedicalmanagementthoracicesophagomyotomy
NutcrackerSyndrome(not=DES):chestpain;extremelyhighamplitudeperistalticwaves(upto400
mmHg);needlongmyotomy,occasionallyesophagectomy
HypertensiveLES
Nonspecificesophagealmotilitydisorder
HopkinsGeneralSurgeryManual 60
II.Secondary
Collagenvascular(SLE,systemicsclerosis,polymyositis,dermatomyositis)
Chronicidiopathicintestinalpseudoobstruction
Neuromusculardisease
Endocrinedisorder

ZenkersDiverticulum
Lossofcomplianceinthepharyngoesophagealsegment;manifestedbyincreaseboluspressure
Musclebiopsieshaveshownhistologicevidenceofrestrictivemyopathycorrelatingwithdecreased
complianceofupperesophagus
RepetitivestressofbolusthroughnoncompliantmusclediverticulumthroughKillianstriangle
(betweencricopharyngeusandthyropharyngeusmuscles)
Primaryreason:dyscoordinationofthesphincterrelaxationwithpharyngealcontractiontogetherwith
impairedsphincteropening
Dx:withbariumswallow;notEGD
Rx:myotomyanddiverticulectomy(orpexyifunfitforresection)vialeftcervicalapproach
Zenkersandepiphrenicarebothfalsediverticuli(mucosaonly);epiphrenicrequireslongmyotomyat
180
0

TractiondiverticuliareTrue:locatedmidesophagus;associatedwithTB/inflammatorydiseases

EsophagealClaudication:chestpaincausedbyaburstofuncoordinatedesophagealmotoractivityunder
ischemicconditions(i.e.esophagealbloodsupplyisinterruptedduringtheseburstsinsituationswhere
bloodflowmayalreadybecompromised)

Esophagealforeignbody:usuallyatpointsofnaturalnarrowing:belowcricopharyngeus,neararchof
aorta,behindrightmainstem;95%areimmediatelybelowcricopharyngeusmusclerigidscopeunderGA
istreatmentofchoice

Esophagealrupture(Boerhaaves):fullthicknessinjury(vs.partialthicknessinjuryofMalloryWeiss);often
leftposterior/lateral;85%dieifdiagnosisdelayed>36hours(Rx:earlyrepair,latediversion)

MalloryWeissTear:repeatedemesis;about10%presentwithmassivehemorrhagegastricbleeding
(usuallylessercurvature);sincearterialbleed,pressuretamponadeoflittlehelpusuallystops
spontaneously;Dxwithendoscopygastrotomy&oversewifdoesntstop

EsophagealPerforation

50%instrumentation,20%trauma,15%spontaneous
3/10kEGD,11/10krigid

Presentationdependson
1.Location,2.Size,3.Elapsedtime,and4.Underlyingpathology/etiology

Cervical:neckpain(especiallywithflexion),crepitus,rightpleuraleffusion
Spontaneous:usuallydistalleft

HopkinsGeneralSurgeryManual 61
NonoperativeCriteria(i.e.containedleak)
1.IntramuralPerforation
2.Transmural,notinabdomendrainswellbackintoesophagus
3.Notassociatedwithobstruction/malignancy
4.Mildsymptoms;noevidenceofsepsis
Treatment:NPO,antibiotics

Diagnosis:
Alwaysget:CXR,EKG,gastroswallow
Poortissueresect
Goodtissue(early)1repair
ReinforcedwithGambistitch&tongueofstomachorparietalpleuralpatch

Cervicalperforations:usuallymanagedwithtranscervicaldrainage;repairiftechnicallyfeasible
Thoracicperforations:iffoundearlycanprimaryrepair(inlayerswithbuttressandthoracicdrainage)
Septic/Lateperforations:ifassociatedwithcancerresection;somefavoresophagealexclusion

Followingcorrosiveingestion:
EGDonlytoproximalmargin(notatallifsuspectperforation)
Emergentthoracotomyindicatedforevidenceofmediastinitisorperforation:severechestpain,
cervicalsubcutaneouscrepitus,widenedmediastinum,PTX,pleuraleffusion
Emergentlaparotomyindicatedfor:signsofperforationorwhennasogastricalkalicontentsfrom
thestomachhavebeenaspirated(directvisualizationofstomachnecessarytoruleoutliquefaction)

Benignesophagealtumors:farlesscommonthanmalignanttumors;leiomyomaismostcommon
usuallyfoundinlower;DONOTbiopsy;resectbyenucleation

BarrettsEsophagus

Semantics
Metaplasia:Achangeofcellstoaformthatdoesnotnormallyoccurinthetissueinwhichitis
found
Dysplasia:Anabnormaldevelopmentofcells,whichisnotcancerous,butcouldbecomecancerous
BarrettsEsophagus(classic):Thepresenceofacircumferentiallengthofatleast3cmofintestinal
metaplasiainloweresophagusabovetheGEJ
BarrettsEsophagus(current):Intestinalmetaplasiaanywhereinthetubularesophagus
ShortSegmentBE:AnysegmentofBE<3cm

Barrettswilldevelopin1015%ofpatientswithsymptomaticGERD
Patientswithhighgradedysplasia(akaCIS),willdevelopadenocarcinomain3050%ofcasesneed
esophagectomy(nodebate)
3040%increasedincidenceofadenocarcinomawithBarretts(comparedtogeneralpopulation);
RiskofcancerprogressioninBarrettsis0.22.1%peryear
Progressiontoadenocarcinomaassociatedwithlossofp53heterogenicityonch17
ControversyexistsforthemanagementofthelargerpopulationofpatientswithBarrettsesophagusbut
nodysplasia,lowgradedysplasia,orindeterminatedysplasia,althoughtheyclearlyrequireclose
surveillance

HopkinsGeneralSurgeryManual 62
EsophagealCancer

Top10cancerworldwide
Geographicvariation17/100kU.S.(Adenocarcinoma,Barretts)100/100kAsia(SCC)

Lymphaticsrunlongitudinallyinesophagusstraighttothoracicduct;hencesmallprimarycanstill
spreadaggressivelyvialymphatics

T1:tolaminapropria(doesnotbreachsubmucosa)
T2:tomuscularispropria(doesnotbreachmuscularispropria)
T3:Adventitia
T4:Adjacentstructures

Noroleforadjuvantchemo/XRT(exceptadjuvantXRTformargin+todecreaselocalrecurrence)

RoleofNeoadjuvantTreatment[4studies]

2025%PRtoinductionchemo/XRTonfinalpath(50%ofthoseCR)
Survivalbenefit(includingLN+)withmoreaggressivelymphadenectomyandresection

1. [KelsonNEJM1998]:5FU+CDDP+surgeryvs.surgery(Prospectiverandomized):nosurvival
differenceat2years35%vs.37%

2. [HerskovicNEJM1999]:Nonsurgicalpatients:5FU+CDDP+XRT(50Gr)vs.XRT(6400Gr)
[differenceisbecausethesechemoagentsmaketissuemoreradiosensitive]12.9monthsvs.
8.9months(significantsurvival,local,distaldisease)

3. [*WalshNEJM1996]:5FU+CDDP+XRT+surgeryvs.surgeryalone(10protocolviolationsvs.1);16
vs.11months(p<0.01);1&3yearsurvivals:52/32%vs.44/6%(p<0.01)
*Controversy:(i)Protocolviolations(ii)Poorsurgicalsurvivalcomparedtopreviousstudies(iii)U/S
andCXRforstaging(noCT)(iv)ProportionofstageIII(13vs.38)

4. [MeluchCancerJ2003]:PhaseIItrialofTaxol/Carbo/5FU/XRT/Surg:mediansurvival22months

Whataboutradicalresection?
StageIII5yearsurvival
US:1017%(standardresection)
Japan:2734%(radicalresection)
[Altorki/SkinnerAnnSurg2001andAltorkiAnnSurg2002]

EUS:valuabletoolforstaging(betterthanCTforTstage;goodforNstaging)

SurgicalApproaches
Cervicalesophagusbestapproachedvialeftneck(cervicalesophagusisleftofmidline)
Thoracicesophagusbestapproachedviarightthoracotomy(IvorLewis)
Loweresophagusbestapproachedvialeftthoracotomyceliotomy

Optionsforresectioninclude:
3hole(leftneck,rightthoracotomy,celiotomy)offerscompleteexposure,butgreatestmorbidity
(ifintrathoracicanastomosis)
Transhiatal:nothoracotomy,cervicalanastomosis(verylowmorbidity,buthigherleakrate)

HopkinsGeneralSurgeryManual 63
Stomach&GutPhysiologyandDisease

Parietalcells:produceH
+
andIF

Somatostatin:InhibitsreleaseofessentiallyallGIpeptides,includinggastrin,insulin,secretin,Ach,and
pancreatic/biliaryoutput;stimulatedbyH
+
induodenum
CCK:fromintestinalmucosacontractsgallbladder,relaxessphincterofOddi,pancreaticenzyme
secretion
Secretin:primarystimulusforpancreaticHCO3secretion
Enterokinase:activatestrypsinogentrypsinactivatestheotherdigestiveenzymes
PeptideYY:releasedfromTIinhibitsH
+
secretion(ilealbrake)

Proximalvagotomy:abolishesreceptiverelaxation,soliquidemptying,butinsolidemptying
Truncalvagotomy:alsosolidemptying(whenpyloroplastydone)andbasalacidoutputby80%
#1symptompostvagotomyisdiarrhea(1/3);Dumpingis10%almostalwaysrespondstodietchanges

99m
Tc:solidemptyingstudy
111
I:liquidemptyingstudy

Leftvagusnerveanteriorhepaticbranch;
Rightvagusnerveposteriorceliacbranch&CriminalnerveofGrassi(cankeepH
+
levelsif
leftundividedpostgastrectomy)
HopkinsGeneralSurgeryManual 64

Pacemakerinproximalstomachongreatercurve:generates23MMC/minute:
Wavegetsstrongerasitapproachesthepylorus

Diabetesis#1causeofgastroparesis

PUD:Gastricvs.DuodenalUlcers
Gastric:
painGreaterwithmeals
H.pylori70%
BloodtypeA
M=F
13%malignantpotential

Duodenal:
painDecreaseswithmeals
H.pylori100%
duetoincreasedacidsecretionordecreasedmucosalprotection
hemorrhage>perforation
BloodtypeO
NOmalignantpotential
M>F
[FigurestakenfromtalkgivenbyJTLenert,2005]
HopkinsGeneralSurgeryManual 65
Followingrepairofperforatedduodenalulcer,naturalhistoryissuchthatapproximatelyofpatients
havenofurtherproblems,havefurtherulcersamenabletomedicalmanagement,andultimately
requireoperation;
Followingrepairofbleedingduodenalulcer,becauseofhigherriskofrecurrence,adefinitiveantiulcer
operationshouldaccompanytherepair(ifsickTVandantrectomy;otherwisemoreselective)

ElevatedFastingGastrin

I.Elevatedacid
ZES
GCellhyperplasia
retainedantrum
renalfailure
gastricoutletobstruction
shortbowel

II.Low/Normalacid
perniciousanemia
chronicgastritis
gastricCA
postvagotomy
onacidsuppression

TypeIgastriculcerassociatedwithTypeAblood;otherswithTypeO;
II(25%),III(15%):Toomuchacid
I(5060%),IV,V:Toolittlemucosalprotection

SurgicalTherapyforPUD:
Nonhealingdespitemedicaltherapyisanindication(especiallytoruleoutcancer)
[algorithm:6weeksmedicaltreatmentEGDrepeat6weeksmedicaltreatmentEGDsurgeryif
nothealed]

Withprolongedvomiting:seeCl

,H
+
(pH),andK
+
(becausekidneyisdumpingK
+
toholdH
+
)

HopkinsGeneralSurgeryManual 66
DistributionofUpperGIBleeding

PUD 55%
Esophagogastricvarices 14%
Arteriovenousmalformations 6%
MalloryWeisstears 5%
Tumors/erosions 4%each
Otherlesions 12%
Includes:DieulafoysLesion:dilatedaberrantsubmucosalvessel(usuallyarterial)usuallyhighinthe
gastricfundus;canleadtosignificantbleeding.
Gastricantralvascularectasia(GAVE):AlsoknownasWatermelonStomachisgenerallyidiopathic,but
maybeassociatedwithautoimmunedisease

GastricVolvulus:2types:
Organoaxial(morecommon):rotationaroundtheaxisoflineconnectingcardiatopylorus
Mesenterioaxial:axisisorthogonaltoabove

GastricDilation:causeshypotension,bradycardia,abdominalpain

Obesity
ClassI:BMI>30
ClassII:BMI>35*surgeryifdevelopcomplicationsofobesity;
*IfBMI>35+significantGERDGastricBypassismuchpreferredoveranantirefluxprocedure
ClassIII:BMI>40surgery
(Note:previousjejunoilealbypassesledtorenalfailurebecauseofdevelopmentofCaOxalatestones)

GastricCancer

GastrointestinalStromalTumor(GIST)
ArisesfrominterstitialcellofCajal(intestinalpacemaker);Ckitmutation/CD117+
Gainoffunctiontyrosinekinase
Resectifpossible;Gleevacformets;roleofGleevacinadjuvantbeingcurrentlyevaluated

Adenocarcinoma:
Resectwith6cmmargins+draininglymphnodes+omentum;noobviousroleforextended
lymphadenectomy
Chronicatrophicgastritisunderliesmostgastriccancer;
otherrisks:adenoma>2cm,TypeAblood,nitrosamines,perniciousanemia

Lymphoma:distinguishbetweenTcell,NHL(nonMALT),andMALT
ExtranodalmarginalZoneBCelllymphoma(lowgradeBcelllymphomaofMucosaAssociatedLymphoid
Tissue,MALT):
50%ofpatientswithgastricNHLhavetheindolentMALTtype
gastricMALTisfrequentlyassociatedwithchronicgastritisandH.pyloriinfection
*thestandardtreatmentforMALTpatients(whoareH.pylori+)isantibioticsandfollowupEGD3and6
monthslater:
ifCRdone
ifPRcontinueantibioticsbeforeXRT(notsurgery)
Surgeryreservedforcomplications
Note:thethickerthelesionthelesslikelyitwillregresswitheradicationofH.pylorialone
HopkinsGeneralSurgeryManual 67
SmallBowelPhysiologyandDisease

MMC:interdigestivemotility;90minutescycles;startsinstomachgoestoTI
PhaseI:quiescence
PhaseII:gallbladdercontraction
PhaseIII:peristalsis
PhaseIV:subsidingelectricactivity
MMCreturntonormal624hoursafterlaparotomy;stomachandcolontakelongertoreturntonormal
tone

SBtransitisapproximately1inchperminute

JejunumabsorbsmoreNa
+
andH2O(paracellular)thanileum

80100cm(30%)ofthesmallbowelisrequiredforabsorption,unlesstheICjunctionisabsent,in
whichcaseapproximately150cmisrequired.

DerangementsseenwithSBresectionleadingtomalabsorption/shortgutinclude:
1.Fat
2.B12
3.Electrolytes
4.H2O

FollowingbowelresectionCa
++
/Mg
++
soapformcationstocomplexwithoxalateincolonoxalate
absorption(worsenedbyVitCconsumption).TreatdeficiencieswithCa
++
,Mg
++
,potassiumcitrate,VitB6,
andavoidVitC

SmallBowelNeoplasms

Representonly5%ofGIneoplasms(12%ofallneoplasms)

Mostcommonbenign: Mostcommonmalignant:
1.Adenoma(2535%) 1.Adenocarcinoma(50%)
2.GIST 2.Carcinoid
3.Lipoma 3.Lymphoma
4.GIST
Allshouldberesected,evenifasymptomatic(needpathtoconfirmlackofmalignantbehavior)
alsoperformregionallymphadenectomywithresection
Adenocarcinomasaremostcommonintheduodenum,theremainingmalignanttumorsaremore
commondistally,withfrequencyproportionaltolengthofsegment(ileum>jejunum>duodenum)
PeriampullaryWhipple
D3/D4segmentalresection+duodenojejunostomy

GISTarisefrommultiplemesodermalcomponents(muscle,nervoustissue,connectivetissue,vascular
elements,fat)

HopkinsGeneralSurgeryManual 68
CarcinoidsarisefromtheKulchitskycellandarefoundintheappendix85%oftime
Mets2%iflessthan1cm;8090%if>2cm
MostcommonlocationsforGIcarcinoids:1.Appendix,2.Ileum,3.Rectum4.Stomach
Smallbowelcarcinoidsaremultiple30%;appendicealusuallysolitary
Urinary5HIAAonlyelevatedifabletobypassfirstpass(extensivelivermets,drainsdirectlyinto
systemiccirculation)
Metabolizestryptophanserotonin5HIAA(measuredinurine);carcinoidsutilize60%of
bodystryptophan,hencesideeffectsoftryptophandeficiency(3Ds:dermatitis,dementia,
diarrhea)

ClinicalManifestations
Dependsonlocation:
i)Foregut:stomachpain,bleeding;bronchushemoptysis,pneumonitis,wheezing
ii)Midgut:appendixobstructiveappendicitis;jejunoiliumobstruction,intusessuption

Localization
CXR,ChestCT,Bariumenema,colonoscopy,superiormesentericangiographyinadvancedtumors
Biopsy:+argyrophilstainissuggestive,butEMofneurosecretorygranulesisgoldstandard
Ifonefound,especiallyincolon,3640%incidenceofsynchronouslesionlookeverywhere
MetastaticdiseasediagnosedONLYbymets,nothistology

Treatment
Appendix:If>1.5cm,involvingbaseofappendix,orregionallymphadenopathypresentright
hemicolectomyindicated
Gastroduodenal:If<1cmendoscopicresection;>1cmormetssubtotalgastrectomyandomentectomy
Rectal:If<1cmendoscopicexcision;12cmresectionwithnegativemargins(23cm);>2cm
lowanteriorresection(LAR)orabdominalperinealresection(APR)iflow
Anytumorwithmetsenblocresection

Outcome>2cmportendsapoorerprognosis
Noninvasiveappendicealandrectal<2cm100%5yearsurvival
If>2cm40%;withlivermets:2040%

Approximately10%ofpatientswithcarcinoidtumordeveloptheCarcinoidSyndromeofflushing,
sweating,diarrhea,wheezing,abdominalpain,rightsidedcardiacvalvularfibrosis,andpellagra
dermatosis

Tumorneedsaccesstovenousdrainagethatescapesportalcirculation,suchaswhen:
1.Hepaticmetsarepresent
2.Venousbloodfromextensiveretroperitonealmetsdrainsintoparavertebralveins
3.PrimarytumorisoutsidetheGItract(bronchial,ovarian,testicular)

CarcinoidCrisis:resultsfromoverwhelmingreleaseofserotonin(liverunabletobreakdown)
CanoccurinORduringmanipulationoftumor
Resultsinhypoorhypertension
Hypertensionshouldbetreatedwithvolumeexpansion,octreotide,andketanserin(somostatin
analog)

HopkinsGeneralSurgeryManual 69
Lymphoma:inadultsusuallyNHLBcell;stageIandIIrequireresection
inchildrenusuallyBurkittsbettersurvivalthanadults

Meckelsdiverticulumis#1causeofsmallbowelbleedinginthose<30yrs.
Oftencontainsgastricmucosa(75%)secretesHClpepticulceration
MeckelsscanTc
99
pertechnetatetakenupbyparietalcells
Mostcommoncauseofobstructionisvolvulusaroundpersistentfibrousbandfromtiptoumbilicus

Angiodysplasia(VascularEctasia):#2causeofsmallbowelbleedinginyoungerpatients;#1causeinthose
>50yrs.

Intussusception(inadults):upto90%resultfromunderlyingpathology(mostoftenatumor;abouthalfare
benign).NoroleforconservativemanagementtoOR

Ileus:lookforcolonicandrectalairtodifferentiatefromamechanicalobstruction
4Categories:
1.Postoperative
2.Paralytic
3.Intestinalpseudoobstruction
4.Colonicpseudoobstruction(Ogilvies)

DiverticulaofGItract:causedbypropulsionforces;10%symptomatic;510%developcomplications
(bleeding,perforation,obstruction,diverticulitisRPabscess);surgeryisonlyindicatedfor
complications/symptoms.
MostCommon:
1. Colon
2. Meckels
3. Duodenum*(seefigure)

4. Pharynx&esophagus
5. Stomach
6. Jejunum
7. Appendix
8. Ileum(excludingMeckels)
*Ifarisesinperiampullaryregionmustprotectduringsurgery

ForMeckelsresectasymptomaticpatientif:
1.youngerthan40,
2.longerthan2cm,
3.fibrousbandpersists,or
4.grossevidenceofheterotopicmucosa
HopkinsGeneralSurgeryManual 70
Mostcommonreasonsforsurgery(i.e.surgeryisreservedforselectcases)inpatientswithCrohnsdisease
1.Failureofmedicalmanagement
2.Obstruction
3.Inflammatorymassorabscess
4.Fistula

Note:IfappendicitissuspectedfindCrohnsdoappendectomyprovidedthebaseofappendixnot
involved

SmallBowelFistula:
Highoutput(500mL/24hours)are3xlesslikelytoclosethanlowoutput
Overallmortality:20%(higherforjejunal;lowerforileal)
InpatientswithCrohnsdisease+highoutputfistulaTPNdoespromotefistulaclosure

SchillingtestforVitaminB12deficiency:revealsatypeofurinaryexcretionofB12similarlytothatseen
withperniciousanemia,exceptnotcorrectedwiththeadditionofIF,butiscorrectedwiththeuseoforal
tetracycline(nonabsorbable)

Appendix

Acomponentofthesecretoryimmunesystem
Appendicitisisinitiatedbyobstructionofthelumen.Inadultsfecalith;inchildrenlymphoid
hyperplasia
Continuedsecretionofmucusleadstopressure(upto126cmH2Owithin14hours)gangrene&
perforation
Theareaoftheappendixwiththepoorestbloodsupplyismidportionofantimesentericside,hence
locationofmostfrequentgangreneandperforation

PresentationofAppendicitis:
Classically,abdominalpainbeginsinperiumbilicalregion(somaticpainfromappendiceal
distention)thenlocalizestositeofappendix(e.g.RLQ)asvisceralpainoncetheserosais
involved.
Anorexiaprecedespain
Vomitingoccursinabout75%ofpatientsandtypicallyfollowstheonsetofpain
Hence:anorexiapainvomitingisobserved95%oftime

Acuteappendicitisisthemostcommoncauseofanacuteabdomeninwomenafterthefirsttrimesterof
pregnancy;theymaypresentwithRUQpain,especiallyduringthelasttrimester;however,pregnancydoes
notriskperse.Immediateoperationiswarranted.ACTscanissafeduringpregnancy.
HopkinsGeneralSurgeryManual 71
ColorectalDisease

Colon:
activelysecretesK
+
andHCO3
absorbsNa
+
againstbothconcentrationandelectricalgradientstoavoidhyponatremia
normallyabsorbs12LofH2O/day;canabsorbupto56L/day

LowerGIbleeding:diverticulosis+angiodysplasia=90%ofcauses(forthose>50)

Angiographycandetectbleedingratesaslowas15mL/min(insomeseriesaslowas0.5mL/min)
TagRBCcandetectbleedingratesaslowas0.51mL/min(insomeseriesaslowas0.1mL/min)
1
st
testtoperformonLGIB(i.e.NGaspirateisbilious),afterstartingresuscitation,isrigidproctoscopy

Volvulus

Cecal(rare);alsoknownascecalbascule

Sigmoid
presentswithSBO
young(2535)
OR(only25%successwithscope)most
doRhemi;butsomeattemptcecopexy
presentwithcolonicobstruction
old,debilitatedpatients(nursinghomes)
70%successwithscopetube
decompressionbowelprep
sigmoidcolectomyduringthat
admission

UlcerativeColitis:
Limitedtomucosaandsubmucosa
56%developcolorectalcancer;riskwithdiseaseduration,pancolitis,PSC
Proctocolectomydoesnothelpsclerosingcholangitisorarthritis,butmayhelpskinmanifestations
20%willrequireproctocolectomy

Ischemiccolitis:
Adiseaseofsmallarterioles
Canoccurinanysegmentofcolon,butmostcommoninwatershedareas,whichrelyon
Meanderingarteries,suchassplenicflexure(Griffithspoint)anddistalsigmoidcolon(Sudecks
point)
Seethumbprintingonbowelwall
Darkdiscolorationoncolonoscopy(black/green)isindicationforsurgicalresection

Diverticulosis

VascularEctasia
50%rightsided
rupturedvasarectaatneckof
diverticulaarterialbleeding;
severe
2550%rebleedrate
mostvisualizeonangiography
virtuallyallrightsided
venousbleeding
85%rebleedrate
only810%extravasationon
angiography
HopkinsGeneralSurgeryManual 72
ColorectalCancer

120,000140,000newcases/year;60,000deaths/yearinU.S.
3
rd
mostcommoncancerinwesternsociety
2
nd
indeaths(tolung)
50%mortality
80%ofpatientspresenteligibleforresection(i.e.20%stageIV);67%ofthesewillrecur;80%ofthese
recurrenceswillbeintraabdominal(liver#1)
5cmgrossmarginforresectionincolon;1cmdistalmucosalmargin(UNfixed)isadequatebecause
rectalcancersrecurbasedonradialspread,ratherthanlongitudinalspread;need35cmofdistal
mesorectalmargin,ifpossible

Staging
Tis:mucosaonly N0:nonodes
T1:intosubmucosa N1:13regional
T2:intomuscularispropria N2:>3regional
T3:intosubserosa
T4:intoadjacentstructure(throughserosa)

StageI:T1,T2,N0,M0 Survival
StageIIA/B:T3(A),T4(B),N0,M0 1year(all):83%
StageIIIA:T12,N1,M0 10year(all):55%
StageIIIB:T34,N1,M0
StageIIIC:anyT,N2,M0
StageIV:anyT,anyN,M1 5yearsurvival:I,II:90%;III:65%;IV:9%

Treatment
StageI,IIcolon:Surgeryalone(currenttrialslookingintoadjuvantchemoforII)
StageIIIcolon:Surgery+Chemo(FLwhatothertrialsthrowin)
StageII,IIIrectal:Surgery+Chemo/XRT(adjuvant)

Withrespecttoadjuvantvs.neoadjuvantXRT,goodevidenceofdownstaging(e.g.tosphincter
preservingoperation)anddecreasedlocalrecurrencerates,butnoevidenceofsurvivaladvantage,
particularlyineraofTME
StageIV:5FU/Leukovorin(FL),Oxaliplatin,CPT11(Irinotechan),Avastin;allcombinations
In2004:IFL(Saltzregimen)+Avastinincreasedmediansurvivalto20.3monthsfrom15.6months(IFL
alone);BUTNOINCREASEIN5YEARSURVIVAL(noregimenhasimpactedthisinnearly20years)

PostResectionFollowUp(Debatable)

*CEA q3months
*colonoscopy q13years
SerialCT q6months
Liverenzymes q23months(LDHismostimportant)
CXR q6months
*mostagreeon

HopkinsGeneralSurgeryManual 73
RisingCEA(happensin70%ofrecurrences)

CTwillmissnearly40%ofrecurrences,and6090%ofthesemissedlesionswillbeintraabdominal
FDGPETis89%sensitivewhenothermodalitiesarenegative,soalgorithmis:

RisingCEAnegativeCTPET;ifnegative,follow;ifpositivetreataccordingly(80%ofthesewillbe
operablelesions)[LibuttiSK,etal.AnnSurgOncol.20018:779]

PETfollow
CEACTPET
+PETtreat(80%willbeoperablelesions)

LiverResectionForColorectalMetastases[Fongscore]:

PrognosticFactor pvalue(forpredictorofsurvival)
Dxfreeinterval 0.002
Tumors>3 0.01
CEA>200 0.05
Size>5cm 0.01
Node+primary 0.05
[FongY,etal.AnnSurg.1999;230:309]

Survivalbasedoncriteria

#factors5yearsurvival(%) OS(months)
0 57 74
1 57 73
2 47 50
3 16 30
4 8 15

ColorectalPolyps

ClassifiedasNeoplastic(adenoma)orNonneoplastic(hyperplastic,hamartomatous,inflammatory)
(Adenoma)Classifiedhistologicallyastubular(6580%),villous(510%),ortubulovillous(10
25%).AspolysizeINCREASES,sotoodoesfrequencyofVILLOUShistology.
Approximately58%ofadenomashaveseveredysplasia,and35%haveinvasivecanceratthe
timeofdiagnosis
Riskofcancerattimeofdiagnosis:tubular(5%),tubulovillous(22%),villous(40%).
For<1cm,riskverylow,for>2cmapproaches50%
Allpolypsdetectedshouldberemovedendoscopically,althoughthisiscontroversialforpolyps<5
mm,whichshould,attheleast,bebiopsied.
Pedunculatedpolypsshouldberemovedviacolonoscopy,butthisisdifficultforlargesessilepolyps
(>2cm),whichharborhighmalignantpotential.Alternatively,multiplebiopsiestaken,andthe
areaismarkedwithinktattoo.
HopkinsGeneralSurgeryManual 74
Formalignantpedunculatedpolyps,ifthereislymphovascularinvasion,poordifferentiation,or
cancerwithin2mmofresectionmargin,colonresectionisindicated.Sessilepolypswithinvasive
cancerrequireformalcolonresection.

HaggittLevel
Welldifferentiatedadenocarcinomainzone1,2,or3polypectomy;zone4formalresection
Poorlydifferentiatedinzone1polypectomy;zone2,3,or4formalresection

Gardnerssyndrome:(FAP)polyposis,desmoidtumors,osteomas
Turcotssyndrome:polyposisandbraintumors
PeutzJegherssyndrome:polyposisandmucocutaneouspigmentation
MuirTorresyndrome:polyposisandskincancer
*Note:theabovedonothavetobecolorectalcancer

HNPCC(HereditaryNonpolyposisColorectalCancer)

ADinheritance
Accountsfor26%ofallcolorectalcancer
AverageageofCRCdevelopment4045
Begincolonoscopyat25
60%by60yearsold;lifetimerisk80%
Germlinemutationinmismatchrepair(MMR)genes+somaticmutationinwildtypeallele
producesaMicroSatelliteInstability(MSI)
2genesaccountfor90%ofmutations(hMSH2andhMLH1)
PredominanceofRsidedcancer(6070%inright/transversecolon)
IncreasedsynchronousandmetachronousCRC
LynchSyndromeICRConly
LynchSyndromeIICRC+othercancer(endometrial,ovarian,stomach,smallbowel,UGI)
Followstheadenomacarcinomasequence,justdoessoquicker
FarebetterthanstagedmatchednonHNPCCwithCRC(i.e.thecancerislessaggressive)

SurgicalTreatment
TotalabdominalcolectomywithileorectalanastomosisrecommendedforAmsterdam+patients
withCRCorMMRcarriers
ProphylacticTAC+IRAasalternativeforMMRcarrieswithadenomasorpatientswithdifficultto
followcolons

HopkinsGeneralSurgeryManual 75
RevisedAmsterdamCriteria(II)
1.HNPCCassociatedcanerin3relatives,oneafirstdegreeoftheothertwo
2.Atleast2successivegenerationsaffected
3.Atleast1diagnosed<50
4.FAPexcluded

FAP(FamilialAdenomatousPolyposis)

AD,100%penetrant
MutationisinAdenomatousPolyposisColi(APC)gene,localizedto5q21
NormalAPCproteinislocalizedtobasolateralmembrane
Truncated,inactiveAPCappearstoallowbetacateninaccumulationinthecellandnucleus,where
itturnsongenesandstimulatescellgrowth
80%familial,but1030%casesarenewmutations
Accountsfor<1%ofcolorectalcancer
Extraintestinalmanifestations:desmoidtumors,osteomas,sebaceouscysts(Gardners);withbrain
tumors(Turcots),CHRPE(hyperplasticretinalcomplicationblindness)
*Mostcommonextracolonicmanifestationisperiampullaryduodenalmalignancy(alsopancreatic,biliary,
gastric,smallintestinal,thyroid)

Desmoidtumorsappearin10%ofcarriesbyage30

Mostcommongeneticalterations:
p53:ch17;mostcommon(85%),tumorsuppressor
APCgene:ch5;sporadic&familial(35&75%,respectively);tumorsuppressor
DCC:ch18;70%cancers/10%adenoma,tumorsuppressor
Kras:ch12;50%cancers;oncogene

HopkinsGeneralSurgeryManual 76
Summary:

GeneticPattern

%ofColorectal
Cancer
ClinicalFeatures
LOH(lossofheterozygosity)

1. Sporadic

2. Familial

3. Inherited(polyposis)
FAP

Gardners

Turcots
6085%

35%

25%

13%

Distaltumors(70%);noFHofpolyps/CRC;aneuploid
DNA;age>60

Distaltumors;FHofpolyps/CRCinseveralrelatives;
aneuploidDNA;age5060

>100polyps;earlyonsetdisease;mutationofAPC
UpperGIpolypsandCRC;retinalfindings

Desmoidtumorsandboneabnormalities

Medulloblastoma
RER(replicationerrorpathway
DNArepairmismatch)

1. Sporadic

2. Familial

3. Inherited
LynchI

LynchII
2035%

20%

6%

10%

Proximaltumors(70%);diploidDNA;better
prognosisthanLOH;age>60

Proximaltumors;diploidDNA;FHofpolyps/CRC;
age5060

CRConly;proximaltumors(70%);40%with
synchronous/metachronousCRC;age4045

LynchI+cancersofendometrium,ovaries,pancreas,
stomach,smallbowel,urinarytract,bileducts

HopkinsGeneralSurgeryManual 77
RectalCancer

3approachesforlocalexcision:
1.Transanal
2.Transsacral(Kraskesprocedure)
3.Transsphincteric*
Unacceptableratesofperinealfistula,notpreferred
*Transsphinctericleadstounacceptablyhighratesoffecalincontinence,notpreferred

Transanalexcisionisreservedfortumorslessthan8cmanteriorand10cmposteriorfromtheanalverge,
notinvolvingsphincters(alsolessthan4cmindiameterandoccupyinglessthan40%ofrectal
circumference)

Preoperativestagingisimportant:patientswithevidenceoftransmural(e.g.tetheredlesiononphysical
exam)orregionalLNinvolvementarenotcandidatesforlocalexcision(unlessconsideredmedicallyunfit
formajorresection)

EvaluationofrectalcancerwithEndorectalU/S:

Threeprospectivestudies[Ota1992,Bleday1997,Steele1999]askedquestionsofadequacyoflocalexcision
adjuvanttreatment.
Conclusions:
1.PatientswithnodalinvolvementneedTME
2.T1lesionsarebestcandidatesforlocalresection
3.T3andT4havehighprobabilityofnodalinvolvementandshouldhaveTME
4.T2lesioncanbemanagedwithTME(goldstandard),butlocalexcision+adjuvantchemoradiation
achievessimilarsurvivalrates,butmayhavehigherlocalrecurrencerates(however,canoftenbesalvaged
byTME)

PostopXRTalonelocoregionalrecurrence,butnoimpactonsurvival
PostopXRT+chemolocoregionalrecurrenceANDsurvival
PreopXRTalone locoregionalrecurrence
PreopXRT+chemodownstagesandimprovesrespectabilityandlocoregionalrecurrence
Rectal Cancer T1
Rectal Cancer T3
Mucosa
Submucosa
Muscularis propria
Serosa
[FigurestakenfromtalkgivenbyJDouglas,2005]
HopkinsGeneralSurgeryManual 78

[PatyPB,etal.AnnSurg.2002;236:522]
Aswithcoloncancermustdofullcolonoscopy,priortosurgery,tolookforsynchronouslesion(4%chance)

Squamouscellcancerofanalcanal:
TreatwithmodifiedNigroprotocol:5FU+mitomycin&XRT(50.4Gr),includingpatientswith
positiveinguinalnodes;notsurgery(8085%curerate)APRforrecurrentdisease(althoughup
to50%responsetocisplatininthissettingofrecurrence)
Riskofmetastaticdiseaserises,andsurvivalratesfallastumorsize>2cm

Pouchitis:Nonspecificinflammationofilealreservoirfollowingilealpouch/analanastomosis;occursin5
40%;usuallyrespondtooralflagyl;chronicproblemin15%ofpatients

FissureinAno:10%anteriorinwomen;nearlyallposteriormidline(90%belowdentateline)
*iffissurenotinmidlinethinkofIBD,TB,syphilis,HIV,Herpes,cancer

Goodsallsrule:iftheexternalopeningofthefistulaisanteriortoanimaginarylinedrawnbetweenthe
ischialtuberositiesthefistulausuallyrunsdirectlyintotheanalcanal;ifitisposteriorthetractcurves
totheposteriormidline;if>3cmfromanuscangoeitherway

Hemorrhoids
External:dilatedveinsofinferiorhemorrhoidalplexus;coveredwithanoderm(belowdentateline);donot
band
Internal:exaggeratedsubmucosalvascularcushions,normallylocatedabovedentateline,hencecoveredin
mucousmembraneofanalcanal,notanoderm;canband
Whenthrombosedbesttreatedbyincisingtheoverlyinganoderminanellipticalfashionandevacuating
thethrombus
MedicalTreatment:bulkagents,stoolsofteners,localagents(e.g.NTG)
[SurgeryoftheAlimentaryTract,VolIV,2001]
HopkinsGeneralSurgeryManual 79
PediatricSurgery

Gastroschisis
Incidence:1:10,000to1:15,000(andincreasing)
Embryology:Mesodermalandectodermaldefectscausedbyischemiaresultingfromprematureinvolution
oftherightumbilicalvein(thisissupposedtohappen67weekspostconception)oravascularaccident
involvingtherightomphalomesentericartery.
Anatomy:
Fullthicknessdefectofabdominalwalltotherightoftheumbilicalcord;umbilicalcordhasa
normalinsertion
Herniationofbowelloops(uncommonlyliver):organsarenotcoveredbyamembrane
Meconiumstainedamnioticfluidcommon,andmaybesecondarytointestinalirritation
Associatedanomalies(510%):Notassociatedwithchromosomalabnormalities.Ileal/jejunalatresiais
mostcommonassociateddefect;cardiacanomaliesarerare

Outcomes:Mortalityrangesfrom725%;ifliverherniatesmortalityincreasesto50%:

Management:Vaginaldeliveryatterm,attertiarycarefacility.Caesareanmaybeindicatedifliver
herniationispresent.Primaryclosureisobtainablein90%ofcases;siloplacementandstagedreduction
necessaryintheremaining10%

Omphalocele
Incidence:1:5000to1:6000(anddecreasing)
Embryology:Impropermigrationandfusionoflateralembryonicfolds.Canbecephalic,caudal,orlateral.
Failureoflateralfoldstofuseresultsinisolatedomphalocele;failureofcephalicfoldsresultsindefects
seeninPentalogyofCantrell.
Anatomy:
Herniationoftheintraabdominalcontentsintothebaseoftheumbilicalcord.
Contentsarecoveredwithanamnioperitonealmembrane.Defectismidline.
Bowel,stomach,andlivermostfrequentlyherniated;amembranemadeupofperitoneumand
amnioncoverstheherniatedorgans.
Theumbilicalcordinsertsintothesac.
AssociatedAnomalies(4060%):Canbeseenwithchromosomalabnormalities(includingtrisomy18,
trisomy13).AlsoseenaspartofPentalogyofCantrellandBeckwithWeidemannsyndrome(seebelow).Other
anomaliesseenoccurwiththefollowingfrequencies:
Cardiacdefects:50%(Overall,VSDismostcommondefectseenwithomphalocele)
GUanomalies:40%
IUGRreportedin20%ofcases

BeckwithWeidemann:macroglossia,viceromegaly,hypoglycemia,macrosomia
PentalogyofCantrell:1.Cardiacdefects,2.Diaphragmaticdefects(2specific),3.Sternaldefect,
4.Abdominalwall(midline,supraumbilical)defect,and5.Ectopiccordis

Outcome:overallmortality4080%(variesdependingonpresenceofassociatedanomalies;cardiac
abnormalitiesdeterminemortalitytoalargeextent)

Management:Cardiacechoandkaryotypeindicated,aswellassearchforotheranomalies.Consideration
ofanomalieshaspriorityunlesssachasruptured.
HopkinsGeneralSurgeryManual 80
Vaginalvs.C/Sdeliverycontroversial:importanttodiagnosepotentialanomaliesthatareincompatible
withlife.C/Sforlargelesionsorlesionscontaininglargeportionsoftheliverseemsprudent.Deliveryata
tertiarycarecenterneeded.

Omphalocele

Gastroschisis
midlinedefect
hasaperitonealsac
coveredabdominalcontentswithin
umbilicalcord
60%cardiacabnormalities
pulmonaryhypoplasia
repaircanbedelayed
defecttorightofumbilicalcord
nosac
fewassociatedabnormalities
10%associatedatresias
immediateinterventionrequired
(closurecanbedelayed,but
interventionmustbeimmediate;Silo
vs.closure)

IntestinalAtresia
Thoughttoresultfrominuterovascularaccidents;associatedwithmaternalcocaineuse
10%aremultiple
Frequency:generallyproximaldistal,althoughmostcommonisasinglejejunoilealatresia
Shortbowelmostlikelytoresultfromjejunalatresia(TypeIII)
Trisomy21mostlikelyassociatedwithduodenalatresia,usuallyin2
nd
portiondistaltoampulla(treatwith
duodenoduodenostomy,notduodenojejunostomy)

Congenitalcysticadenomatoidmalformationofthelung(CCAM)
Lobarhamartoma;overgrowthofterminalbronchioles
Rare;Nosexpredilection,usuallyunilateral.Notassociatedwithotheranomalies.

Types:Macrocystic:>5mmcyst
Microcystic:<5mmcystorsolid;poorerprognosis,morelikelytobecomplicatedbyhydrops.

TypeI macrocystic,generally>2cm
TypeII microcystic,areasofuninvolvedlung
TypeIII involvesentirelobe,nocysticspaces(allsolid)

Complications:
Hydrops:vascularcompressionbytumordecreasesvenousreturnandmyocardialcontractility
Polyhydramnios:causedbyesophagealcompression
Pulmonaryhypoplasiaandpulmonaryhypertension:compressionofotherwisenormallungtissue
bytumor(canresultinacuterespiratoryfailure)

DiagnosisismadebyU/Sfindingsofnonpulsatileintrathoraciclungmass;resectiontiming
dependsonsymptoms
15%willregressspontaneously

PulmonarySequestration
Distinguishbetweenintraandextralobar(samearteriesin,differentveinsout):
Intralobar:aortain,pulmonaryveinsout;muchmorecommonthanextralobar
segmentectomy/lobectomy
Extralobar:aortain,systemicveins(azygous,hemiazygous)out;nobronchialconnection;distinctand
separatepleuralinvestment(oftenasymptomatic);resectifsymptomatic
Bothpresentwithrespiratoryinfection,notdistress;clueislowpositionofabscesses(vs.uppersegmentsof
lowerlobes)
HopkinsGeneralSurgeryManual 81
CongenitalLobarEmphysema
Massivehyperinflationofasinglelobeoflung;usuallyupper/middle(LUL>RML>>RUL>lowerlobes)
haverespiratorydistressatbirth;rarepresentationafter6monthsofage
M:Fratiois2:1
10%haveseveresymptomslobectomy

Malrotation:LigTreitzistorightofvertebralcolumn;duodenumhasacorkscrewconfiguration(onUGI)
Laddsbands(adhesionsfromRcolontoRpericolicgutter)contributetoduodenalobstruction.
TheyareremnantsoftheRPattachmentsthatwouldnormallysecureRcolon.
Mostchildrenwithmalrotationpresentwithinfirstyearoflife
Suddenappearanceofbiliousvomitingismalrotationuntilprovenotherwise
Mayormaynothaveabdominalpain/tenderness
GoldstandardfordiagnosisisUGI
IfmalrotationwithvolvulusorifsicktoOR
IfasymptomaticandnovolvuluselectiveLaddsprocedure
Operation:counterclockwiserotationofvolvulus;mobilizeduodenumlyseLaddsbandswiden
mesentericbaseruleoutobstructionappendectomy(sincececumnolongerinRLQ)smallbowelto
right/colontoleft(createnonrotation)

NEC:MostcommonsurgicalemergencyinNICU(17%ofNICUadmissions)
Those<2kgmakeup80%ofcases;primarilyadiseaseofprematurenewborns(3032weeks)
caninvolveanypart;mostcommonisSMAwatershedarea(distalileum/cecum)
Riskfactors:lowbirthweight;prematurity;maternalcocaine;indomethacin(forPDA);enteral
feeding(formulavs.breast),asphyxia,exchangetransfusions,anemia,umbilicalarterial/venous
catheterization
Presentation:toxicplateletcount;pneumatosisonAXR(absentin20%)
*AVOIDcontraststudies
Surgeryindicatedforperforation,+paracentesis,clinicaldeterioration,persistentloop(somehavealso
advocatedforPVgas)

Intussusception:frequentcauseofbowelobstruction

90%in3months3yearsold
10%haveanatomicleadpoint(hypertrophiedlymphoidtissue,polyp,Meckels,submucosal
hemorrhage)
U/Sinnoninvasiveprocedureofchoice;canshowpseudokidney=targetsign
Successofaircontrastenemainuncomplicatedcases5090%;canreducewithcolumnupto80
cmH2O
OR:righttransversesupraumbilicalincision
Reduce:proximalmilking(NEVERpullintussuceptumout)

HopkinsGeneralSurgeryManual 82
ImperforateAnus(AnorectalMalformationARM)
LowARM:maypresentlate;donotrequirecolostomy;dilationsfirstthenanoplastyorlimitedposterior
sagittalanorectoplasty(PSARP)
HighARM:fistulatourethra,bladderneck,vagina,orcloaca(commonopening)
Requirecolostomy(usuallya2stageprocedure)
PSARP
Renalabnormalitiesmostcommon
MaybepartoftheVACTERLsyndrome:Vertebralanomalies,imperforateAnus,Cardiac
abnormalities,TEfistula,Esophagealatresia,Renalanomalies,andLimbabnormalities)

MeckelsDiverticulum:truediverticula;outpouchingonantimesentericsideofsmallbowel
Ruleof2s:
2%ofpopulation
2%symptomatic
<2feetfromileocecalvalve
2incheslong
2presentations(bleedingandobstruction)
2typesof(heterotopic)mucosa:gastric&pancreatic
Mostcommonlypresentsin<2yearsolds

BiliaryAtresia
hepaticU/SandHIDAtodiagnoseearly
ruleoutcholedochalcyst,giantcellhepatitis,ducthypoplasia
initialgoalofsurgeryistoconfirmdiagnosis;ifGBidentifiedperformcholangiogram
hepatoportoenterostomy(Kasaiprocedure)forbiledrainagemostsuccessfulifdonebefore2
monthsofage(successmuchlessifchild>3monthsold;drainwell,drainok,nodrainage)
ifKasaifailed(poorbiliarydrainage),latediagnosis,progressiveliverfailurerequiretransplant

TracheoesophagealFistula(haveassociatedVACTERLsyndrome)
Incidence:1:30004000;30%havecardiacabnormalitiesECHOfirst

TypeA:Gastrostomytubeandgrowthbeforerepair;NGTtodrainproximally
TypeC:Repairisdependantonhealthandsizeofinfant;ifhealthy+>2500gmprimaryrepair;
Ifnotligatefistula,gastrostomy,drainageofblindpouch,delayedrepair
TypeD:Bronchoscopytoconfirmpresenceof1or2fistula;repairviarightthoracotomy
TypeE:Presentslater(weeks)Hisusuallyhighrepairthroughneckincision
Placeupright,placeNGTforsuction,NPO,avoidvigorousbagging,checkCXRfortubecurl,ECHO
HopkinsGeneralSurgeryManual 83
PyloricStenosis
Presentin3/1000livebirths
Mostcommoncauseofsurgicallycorrectablevomitinginnewborn
Presentswithnonbilious,oftenprojectile,vomiting,usuallyby36weeksofage;4:1M:F
Physicalexamrevealsoliveabout90%ofthetime
Examissufficienttodiagnose;UGIifnopalpableolive
TreatmentisRamstedtpyloromyotomy,butnotemergently(fixelectrolytesfirst,fluidbalance)
Associatedmalformations:malrotation,hepaticglucuronyltransferaseability(jaundice)

CongenitalDiaphragmaticHernia
Bochdaleck(posterolateralusuallyleft)andMorgagni(anteriomedial)
presentshortlyafterbirth(mayhavefewnormalhours)
CXRshowsloopsofboweland/orstomachinchest
Resuscitation/stabilizationispriorityovertimingofsurgery(includingECMO)
asinadults,repairisviaabdomen

HirschsprungsDisease
Morecommoninmales(7080%)
Lackofganglioncellsfromrectumtostomach(althoughrareproximaltocolon)
Rectosigmoidismostcommonlocation
DiagnosewithBE(lookforsigmoid/rectumratio>1),suctionrectalbiopsy(definitive)
Treatwithresectionandpullthrough(1stagevs.2stage);1stageassociatedwithanastomotic
disruption

Managementofundescendedtesticle:mayoccurspontaneouslyduringfirstyearoflife;ifnot
orchiopexyby1yearofage(riskofinfertility,butnotriskofcancer:risk1/4000,i.e.40foldincrease)

Umbilicalhernia:nourgentneedforrepair,unlessverylarge;ifnotspontaneouslyclosedwhenschoolage
electiverepair

Inguinalhernia:repairismostcommongeneralsurgicalprocedureperformedoninfants;M>F(3:1),R>L;
allshouldberepairedatthetimeofdiagnosis;bilateralrepairisperformedbysomeuptoage5

Pediatricmalignancy

#1overallisleukemia,#2isCNS(=#1solidtumor),#3isneuroblastoma
#1solidorgantumor(excludingintracranial)isneuroblastoma;90%have VMA; HVAworse
prognosis;cellsderivedfromneuralcrestandmayariseanywherealongsympatheticganglia
(adrenalmedullaismostcommonlocation);30%cure;associatedwithNmyc
Location:75%adrenal,20%posteriormediastinum,4%organofZuckerkandel,1%cervical
Favorableprognosis:age<1year;stage1,2,or4S,lowtumormarkers,normalNmyc,DNAindex>
1.0
Wilmstumornephroblastoma(mostcommoninchildren>2yearsold)80%curedwith
nephrectomy;chemoregimenisvincristine,Dactinomycinanddoxorubicin(stageIII)
Hepatoblastomaismostcommonlivertumorinchildren;AFPoften;ifHCGcanresultin
precociouspuberty;surgicalresectionistreatment

HopkinsGeneralSurgeryManual 84
SpleenandSplenectomy

Functions:
FilterabnormalRBCs,storeplatelets,produceTuftsinandProperdin(opsins),produceAb(esp.
IgM),siteofphagocytosis(DoesnotstoreRBCs)
Whitepulp:lymphatic
Redpulp:phagocytic

BloodSupply:splenicarteryandshortgastricveins(gastroepiploic)
Drainage:splenicveinandshortgastricveins(gastroepiploic)
1520%ofpeoplehaveaccessoryspleens
Spleenisapproximately1%oftotalbodyweightreceives510%ofcardiacoutput

Mostcommoncauseofsplenicveinthrombosis:Pancreatitis
PatientswithUlcerativeColitisdevelophyposplenism

DefinitionofHypersplenism:
Hyperfunctioningspleen,lossofbloodelements,largespleen(splenomegaly),hyperactivebonemarrow
tryingtokeepupwithlossofbloodelements;spleniccellularsequestration
Primary:Adiagnosisofexclusionwillrespondtosplenectomy
Secondary:e.g.Resultofhepaticdiseasenosplenectomy

oftotalbodyplateletsarestoredinspleen

DelayedSplenicRupture:Asubcapsularhematomamayruptureatalatertimeafterblunttraumaupto
2weekslater.Presentwithshockabdominalpain

Signs/SxofRupture:
HemoperitoneumandKehrsSign(referredpaintotipofleftshoulder),LUQpainandmass(Ballances
Sign)

Diagnosis:
AbdominalCTifstable;
U/Sexlapifunstable

Treatment:
Nonoperativeif:stable,isolatedinjurywithouthilarinvolvementorcompleterupture
Ifunstable:splenectomyorsplenorrhaphy(salvageoperationwithwrappingvicralmeshandtopical
hemostatagents/partialsplenectomy)

HopkinsGeneralSurgeryManual 85
Indicationsforsplenectomy:
Hyperslenism,Gauchersdisease,splenicveinthrombosis,sicklecelldisease,thrombocytopeniaviadrug
abuse,sphereocytosis,lymphoma(esp.Hodgkins),ITP,TTP,splenictumors/trauma,Feltyssyndrome,
lymphroproliferativedisorders(NHL,CLL),HairyCellleukemia,Thalmajor,notG6PDDeficiency

ITP:(Immune)
Autoimmune(usuallyantiplateletAb)plateletdestructionleadingtobleedingand
purpura
Spontaneousremissionoccursinmostchildren;only25%ofadults
Splenomegalyisrare
#1causeoffailedprocedureismissedaccessoryspleen

ErythrocytesMembraneAbnormalities
Hereditaryspherocytosis:abnormalityofspectrinosmoticfragilitysplenectomyis
onlyeffectivetherapy.MostcommonindicationforsplenectomyinUS(nontrauma)

RedCellEnzymeDefects
G6PDdeficiency:mostcommonenzymaticabnormalityofRBC;mostpatientsrequireno
treatment,butsomevariantsimprovewithsplenectomy

AutoimmuneHemolyticAnemia(AIHA):
IfsecondarytoIgGantibodies(warmantibodytype)mayrespondtosplenectomy;
ButifIgMmediated(coldagglutinindisease)liverissightofRBCsequestrationnosplenectomy

TreatmentofchoiceforTTP(Thrombotic):Plasmapheresis,steroids(splenectomyaslastresort);
TTPisadiseasecharacterizedbyocclusionofarteriolesandcapillariesbyhyalinedepositscomposedof
aggregatedplateletsandfibrin

Labtestsfollowingsplenectomy:50%increaseinWBC,markedthrombocytosis,HowellJollybodiesin
peripheralsmear(failuretoseeHJbodiesfollowingsplenectomymissedaccessoryspleen)

Possiblecomplications:
Thrombocytosis(treatwithASAifplatelets>1million),subphrenicabscess,gastricdilation,
OverwhelmingPostSplenectomySepsis(OPSS)

OPSS:
<1%inadults,morecommoninchildren(bothincidenceandmortality)
Morecommonfollowingsplenectomyforhematologicdisease(vs.trauma)
Streppneumo,Meningococcus,HIB,E.coli
Vaccinatepreopifpossible(Pneumcoccus,Meningococcus,HIB)
AggressivetreatmentwithPCNforallminorinfections
HopkinsGeneralSurgeryManual 86
HepatobiliaryAnatomy,Physiology,andDisease

Mostcommonarterialvariations:
1.Lefthepaticarteryarisesinpartorcompletelyfromleftgastricartery(23%)
2.RighthepaticarteryarisesinpartorcompletelyfromSMAandpassesbehindheadofpancreas(25%)
Practicalpoint:TheRHA(oraccessoryRHA)istheonlystructuretotherightoftheCBD

Anatomically,theliverisdividedintosectorsbytheRHV,MHV(80%joinsLHV;20%intoIVC
directly),andFalciformligament
Eachsectorissubdividedintosegmentsbytheportaltriad(abovevs.below);eachsegmenthasits
ownportalpedicle
Rightportalveinbranchesbeforetheleft;andleftPVrises(i.e.seenonhighercutsonCT)
OnU/S,portalveinshaveprominenthyperechoicwallsbecauseoftheaccompanyingintrahepatic
Glissoniansheath
Hepaticveinsappearwallless

Flowtowardsliveristermedhepatopedal;Flowawayfromtheliveristermedhepatofugal

HepaticAbscess
usuallyinrightlobe
Pyogenic Amebic
entryviabiliarytreeorportal
vein
Rx:drainage
growsE.coli,bacteroides,strep
entryviaportalvein
Abxonly(flagyl)
cultureusuallysterile
HydatidcystEchinococcalcyst:+casoniskintest,+indirecthemaglutination;appearsascalcifiedcystic
lesioncontainingmanycystsresect(pericystectomy)
[FiguretakenfromWebMD,2000]
HopkinsGeneralSurgeryManual 87
BenignLiverTumors

Hemangioma HepaticAdenoma FocalNodularHyperplasia

History

CTfindings

MRIfindings

RBCscanfindings

LiverScan

Management
Oftenasymptomatic,
symptomsiflarge*;most
common

Peripheralenhancementand
delayedcentralpooling

T1:hypointense
T2:extremelyhyperintense

Poolingondelayedimages

colddefect

Asymptomaticconservative
+followup;
Symptomaticresectby
enucleation
OCuse;oftensymptomatic;
bleedingorrupture

Hypodense,heterogeneous
mass;arterialenhancement

T1:hypointense
T2:hyperintense

Nochange

colddefect

Resect;ruptureorhemorrhage
riskrelatedtosize;malignant
potential
OCuse(lessassociationthan
adenoma);usuallyasymptomatic;
2
nd
mostcommon

Centralscar,whichenhances

T1:isointense
T2:hyperintense+centralscar

Nochange

Nodefect;sulfurcolloidtaken
upbyKupfferscellslesion
blendswithsurrounding
parenchyma

Conservative;Resectonlyif
symptomaticoruncleardiagnosis
*KasabachMerritsyndrome:consumptivecoagulopathyorCHFduetohemangioma

HepatocellularCancer

3
rd
highestcancermortalityworldwide(lungis1
st
,stomach2
nd
asof2004)
Risks:HepB,HepC,cirrhosis(ethanol,hemochromatosis,PSC,1antitrypsindeficiency),
aflatoxins,clonorchissinensis(flukes)
SerumAFPin5595%
Size,stage,andhistologicgradeareimportantprognosticfactors
Bloodsupplymostlyfromhepaticarteryenhancesarterialphase;iso/hypodenseportalphase
(canhavecentralscar)
Resectionif:
Singlelesion<5cm;upto3lesionseach<3cm
OkudaI,CLIP01,BCLC0orA
ChildsAandB(notC)
Noportalhypertension(clinicallyorPVP>10mmHg)
Tumorrecurrenceoccursin70%ofcasesat5years

Transplantif:
Singlelesion<5cm;upto3lesionseach<3cm(Milancriteria)
OkudaI,CLIP01,BCLC0orA
ChildsBorC(notA)

Fibrolamellarvariantmayhavebetterprognosis

HopkinsGeneralSurgeryManual 88

BiliarySystem:

BloodsupplytosupraduodenalbileductarisesfromRHAandbranchesofGDA(retroduodenalartery)
andlielongitudinallyatthe3and9oclockpositions

Bileisrequiredfor:
vitaminDabsorption
bilirubinexcretion
cholesterolexcretion(solublizedinphospholipidsvesicles)

Stonesassociatedwithilealdisease/resectionandTPNusearepigmentedstones,notcholesterol
stones(arecomposedofcalciumbilirubinate)
Primarycommonductstones(thoseinduct>2yearsaftercholecystectomy)arepigmentedand
relatedtobiliarystasisandinfection,notcholesterol
NaturalHistoryofAsymptomaticGallstones:Symptomsdevelopinabout13%ofpatientsper
year.Hence,observeasymptomaticstones.
Complicatedgallstonediseasedevelopsinabout35%ofsymptomaticpatientsperyear.

DdxforLiverMassonCT:
HopkinsGeneralSurgeryManual 89
Bilecirculation:

Hepaticsynthesis=fecallosses=300600mg/day

Inthepresenceofacutecholecystitis(calculousoracalculous)allgallbladdersfailtovisualize
followingtechnetium99mpertechnetateiminodiaceticacid(
99m
Tc)administration,becauseofcystic
ductobstruction(actualorfunctional)

Between8and18%ofpatientswithsymptomaticgallstoneshavecholedocholithiasis

SmallCBDstonescanbeclearedbyflushingtheductfollowingglucagonadministration(torelax
sphincter)

Acalculouscholecystitisresultsfromgallbladderstasisdistentionischemia

Cholangitis:requiresbothbacteriainbileandstasis;commonductpressure>20cmH2O

PreopERCPshouldbeperformedifanyofthefollowingarepresent:
1. cholangitis
2. jaundice
3. stonesseenonU/S
4. dilatedCBD

IOCisnotconsideredadequateunlessthefollowingarevisualized:
1. Bothrightandlefthepaticducts(ifnotbeconcernedaboutducttransaction)
2. CBDwithoutfillingdefect
3. Freeflowofcontrastintoduodenum(tryglucagonifnotseeing)
[FiguretakenfromRUSHreviewofsurgery,2000]
HopkinsGeneralSurgeryManual 90
Gallbladder

ConcentratesbilebyactiveabsorptionofNa
+
,Cl

(H2Ofollows);cholecystectomyworksby
eliminatingreservoirforcesamorecontinuoussourceofbileandeliminateschanceforsludge
andstoneformation.
70%ofpatientswithEF<30%(normalis>35%)onCCKHIDAbenefitfromcholecystectomy,
althoughthismaystillbecontroversial
1020%ofpatientswithsymptomaticgallstoneshavecholedocholithiasis
Bydefinitions:stonesinCBD>2yearsaftercholecystectomyareprimaryCBDstones(pigmented,
relatedtobiliarystasisandinfection),ratherthancholesterolstones;needsphincterotomyand
extraction
Porcelaingallbladderhas3065%riskofcancercholecystectomyindicated
Gallbladderadenocarcinoma:90%havestones.Cholecystectomyadequateifconfinedtomucosa;if
grosslyvisibletumorregionallymphadenectomy,wedgesegmentV,skeletonizeportaltriad
Gallbladderpolypscanbemalignant;riskisrelatedtosize;hence,shouldremoveGBforpolypis
symptomaticor>10mm;sessilemorelikelytobemalignant;pedunculatedmorelikelybenign

DiagnosisofCholecystitis

Threemostsensitivesignsofcholecystitis:
1.SonographicMurphyssign
2.Wallthickening>4mm
3.Pericholecysticfluid

Postoplapcholepatientnotdoingwell,think:
Viscousinjury(e.g.duodenum)
Ductinjury
Bileleak
RetainedCBDstone
Cysticductstumpleak

Managementofgallstoneileus:
1.Removestone(viaenterotomyproximalatsiteofobstruction)
2.Runentirebowel
3.Inacutesetting,especiallyelderly,reservecholecystectomyforlater(riskofrecurrence510%)&
repairbiliaryentericfistula

RatesofPositiveBileCultures

Bileculturesarepositiveinapproximately:
1.540%ofchroniccholecystitis
2.3070%acutecholecystitis
3.6080%ofcholedocholithiasis
4.2530%ofmalignantobstruction
5.100%ofbileductstrictures

Acalculuscholecystitis(pathophysiologyinvolvesischemia)mostcommonin:cocaineuseandHIV

Sclerosingcholangitis:ERCPtodiagnose;multiplestrictures/dilations(beadedappearance)

HopkinsGeneralSurgeryManual 91
Bismuthclassificationsystemofbileductinjury:

Note:Type5injuryinvolvesaseparateinsertingsectoralductwithorwithoutinjuryofthecommonduct

CholedochalCystsTodaniClass

*20foldincreaseinbileductmalignancyifleftuntreated;F:M4:1

I Solitaryfusiformextrahepaticcyst(82%)
II Extrahepaticsupraduodenaldiverticulumsecondgallbladder(3%)
III Intraduodenaldiverticulum,(choledochocele)(5%)
IVA Fusiformextrahepatic&intrahepaticcysts
IVB Multipleextrahepaticcysts(A+B=9%)
V Multipleintrahepaticcysts,(CarolisDisease)(<1%)

*Currenttheoryisthatcystsoccurbecauseofbilereflux,whichresultsfromanabnormaljunctionofthe
biliaryandpancreaticducts;inotherwords,thecongenitalaspectofthediseaseistheductalabnormality
thecystsareaconsequenceofthis

Management:

I Completecystexcisionwithhepaticojejunostomy
II Excisionofcystwithprimarycholedochorrhaphy
III Largesphincteroplasty
IV&VSelectivemanagementwithhepaticresectioniflocalizedbileductcyst,extrahepaticcystresection,
hepaticojejunostomywithlargestents,advancedbiliarycirrhosismayrequirehepatictransplantation
[Figuretakenfromwww.uptodate.com]
HopkinsGeneralSurgeryManual 92
TransportofBilirubin

BilirubinissynthesizedintheRESfrombiliverdin.Insolubleunconjugatedbilirubin,reversiblyboundto
albumin,istransportedtotheliver,andintocytoplasmofhepatocytes.Theenzymeuridinediphosphate
glucuronyltransferaseconjugatesthebiliwitheitheroneortwomoleculesofglucuronicacidtoform
watersolublebilirubinmonoanddiglucuronide.Thisissecretedintothebilecanaliculus.

Intheterminalileum&colon,bilirubinisconvertedtourobilinogen,1020%ofwhichisreabsorbedback
intoportalcirculation

Bileis80%bilesalts,15%lecithin,5%cholesterol.Gallstonescanbeclassifiedascholesterolstones,black
stones,andbrownstones:
Cholesterolstonesformwhenbilebecomessupersaturatedwithcholesterol
Blackstonesformwhenbilebecomessupersaturatedwithcalciumsalts(primarilycalcium
bilirubinate)
Brownstonesfromwhenbileacquiresstasisinducedbacterialcontamination

GBconcentratesbilebyactivereabsorptionofNa
+
,Cl

;H2Othenfollows
Bilepoolof5gisrecirculatedq4hourslose0.5g(10%)daily

AssessmentofJaundice

Askwhy?
Excessbiliproduction?
Deficienthepatocyteuptake?
Deficientconjugation?
Deficienthepatocytesecretion?
Deficientbilisecretion?

Groupedasprehepatic,hepatic,andposthepaticcauses

Checkfractionatedbililevels

1. Predominanceofunconjugated(indirect)suggestsprehepaticetiology(hemolysis)orhepatic
deficienciesofuptakeorconjugation
2. Predominanceofconjugated(direct)suggestsdefectsinhepatocytesecretionintobileductsorbile
ductsecretionintoGItract
3. Combinedelevationsuggestscomplexproblem,usuallyacquiredliverdamage

HopkinsGeneralSurgeryManual 93
LaboratoryInvestigationofHyperbilirubinemia

Jaundicemayresultfromoverproductionofbilirubin(hemolysis),impairedconjugation(Gilberts
syndrome),impairedintracellularmetabolismorexcretion(drugeffect),hepatocyteinjury(hepatitis),bile
ductinjury(primarybiliaryandsclerosingcholangitis),andlargeductobstruction(stone,tumor,sclerosing
cholangitis)

Firstinvestigatebyfractionation:

Unconjugatedhyperbilirubinemia(hemolysis,Gilberts)isusuallydefinedaslevelsgreaterthan
80%oftotalbilirubin,whichshouldRARELYexceed5mg/dL
Conjugatedhyperbilirubinemia(hepatocellularorbileductdisease)existswhentheconjugated
fractionexceeds50%ofthetotallevel
bilirubinisanirreversibly(covalently)albuminboundformofbilirubinfoundinthesettingof
longstandingconjugatedhyperbilirubinemia;notfilteredthroughkidneys;T1/2=18daysreason
forslowdeclineofTBfollowinglongstandinghyperbilirubinemia,especiallyinpatientswithrenal
failure
Ingeneral,abilirubinof25mg/dl,ofwhichmostisunconjugated,inanotherwisehealthyadultis
Gilberts(25%ofpopulation),hemolysis,orboth.Thehemolyticcomponentwillbemorelikely
LDHandAST(bothinRBCs)arealsomildlyelevated

Alkalinephosphatasecomesfromliverandbone.MeasurementofGGT(gammaglutamyltranspeptidase)
isoftenusedtoindicatethesourceoftheAP.NormalGGTsuggestsnonhepaticsource,suchas
osteoblasticbonelesions,orcertainothertumors.SpuriouselevationsinAPmayalsobeseenafteralbumin
infusionifthealbuminisderivedfromplacentalblood,whichisrichinAP

SphincterofOddi

Regulatesflowofbileintoduodenum
Composedof4sphincterscontainingbothcircularandlongitudinalsmoothmuscle
Lengthisabout46mm
Basal(resting)pressureaverages13mmHg(515)
Undergoesphasiccontractionswithafrequencyof4/min;eachwithdurationof8seconds
Pressureincreasesto13015mmHg(50150)
RelaxationoccurswithCCKstimulationandparasympatheticstimulation;glucagons(tryIV
glucagonstopasssmallstones)
MSO4,sympatheticstimulationincreasessphinctertone

HopkinsGeneralSurgeryManual 94
PortalHypertension

DefinedasPVPthatexceedsnormalvalueof36mmHg;eitherresistancetoflow(common)orportal
bloodflow(uncommon);bleedingrequiresapressure>12mmHg
Bleedingfromrupturedgastroesophagealvaricesisresponsibleforgreatestmortalityandmorbidity
Maybeclassifiedaspresinusoidal,sinusoidal,orpostsinusoidal:

Presinusoidal Sinusoidal Postsinusoidal

Extrahepatic
Portalveinthrombosis(congenital
atresia,pylephlebitis,
hypercoagulablestate,trauma,
adjacentinflammation,mechanical
obstructiontumors/nodes)

Intrahepatic
Schistosomiasis
congenitalhepaticfibrosis
myeloprolifertiivedisorders
PBC
fattymetamorphosis
toxichepatitis
Wilsonsdisease
*Cirrhosis
Extrahepatic
BuddChiari(extrahepatic):
congenitalwebs,compressive
neoplasms,trauma
cardiaccauses(constrictive
pericarditis,CHF)

Intrahepatic
BuddChiari(intrahepatic):veno
occlusivedisease,hypercoagulable
state
Betterprognosisthansinusoidal,postsinusoidal
*Overallmostcommoncause

Also,highflowportalhypertensionresultingfrom:
AVfistula(HAPV,splenic,mesenteric)
massivesplenomegaly

NaturalHistory
ofpatientswithcirrhosiswilldevelopvarices2033%willbleed
withsupportivemanagementalone30%willrebleedwithin6weeksand70%within1year
initialbleedisfatalin3050%ofcirrhoticpatients
factorsassociatedwithbleeding:large(>small),tortuosity,cherryredspot,presenceofgastric
varices,ChildsclassC(vs.A,B)
varicesbleedbyruptureratherthanerosion
portalsystemicshuntshavebeenshowntohavenoroleinprophylacticmanagementonesophageal
varices(butblockersdo)
Vasopressin+NTG>>Vasopressinalone[vasopressincausessplanchnicarteriolarvasoconstriction]
Octreotide[50mcgbolusfollowedby50mcg/hrx4872hours]isbest1
st
treatmentforbleeding
varicesandisaseffectiveassclerotherapy[PlanasR,etal1994Hepatology20:370]

HopkinsGeneralSurgeryManual 95
MassiveUpperGIBleed:
Allcomers:40%PUD,18%gastritis,13%esophagealvarices,9%MalloryWeisstear,9%other
Knowncirrhotic:53%esophagealvarices,22%gastritis,20%PUD

4Maincomplicationsofcirrhosis
1. portalhypertension
2. ascites
3. hepaticencephalopathy
4. malignancy(primaryhepatic)

SAAG(SerumAscitesAlbuminGradient)

If>1.1gm/dLindicatesportalhypertension.Shouldberesponsivetomedicalmanagementconsistingof
sodiumrestriction(2000mg/day)+oraldiuretics(spironolactone+lasix)
FluidrestrictwhenNa
+
fallsbelow120mmol/L

TIPSIndications

AcutevaricealhemorrhageisthemostcommonindicationforTIPS,followedbyrefractoryascitesand
hepatichydrothorax.
TIPScontrolsbleedingin75%to100%ofpatients;theefficacyissimilarforbothesophagealandgastric
varices,andrebleedingdoesnotusuallyrecurunlessthereisshuntdysfunction.TIPS,however,may
noteliminateisolatedgastricvaricesinupto50%ofpatients.Whenrebleedingoccursinspiteofan
openshunt,angiographicobliterationofthevaricesmayarrestbleeding.Despitegoodresultsfor
controlofbleeding,shorttermmortalityremainshighinpatientswhohaveTIPSforvaricealbleeding.
Asaresult,bettercriteriaforselectionofpatientshavebeensought.
Arecentstudyshowedthatpatientscouldbestratifiedby4clinicalvariablesbeforeTIPSinorderto
predictsurvivalafterTIPSplacement.Overall,allpatientsundergoingTIPShada19%1monthanda
48%1yearmortality.OfallvariablesavailablebeforeTIPSthefollowing:
1. varicealhemorrhagerequiringemergentTIPS,
2. bilirubin>3.0mg/dL,
3. alaninetransaminase>100IU/L,and
4. encephalopathy
wereassociatedwitha90%mortalityat1month.VaricealhemorrhagerequiringTIPSwasthe
strongestindependentpredictorofmortality.
WhenapatientwithTIPSpresentswithrecurrentbleeding/ascites1
st
testtoperformisDopplerU/S
toruleoutshuntthrombosis

HopkinsGeneralSurgeryManual 96
SurgicalShunts:
Inpresenceofsevereascitessidetosideportocavalshunt(ormesocavalshunt)ispreferable
Fewindicationsfordirectportalveinanastomosis(ratherthansplenic/SMVanastomosis)

Smalldiameterinterpositionalshunt WarrenShunt(distalsplenorenal)
(Sarfeh)

[Surgery:ScientificPrinciplesandPractice3
rd
,2001]
HopkinsGeneralSurgeryManual 97
Pancreas

pan(all)+creas(meat)theonlyorganthatcaneatthebody

Ventralbuduncinateprocessandinferiorportionofhead
Dorsalbudremainderofgland

Isletcellsare12%ofpancreaticmass,butreceive1025%ofarterialbloodsupply
Oftheisletcells,cellscompriseabout70%andarelocatedatthecenteroftheislet

Annularpancreas:doublebubbleonAXR;treatobstructionwithduodenojejunostomy(noresectionof
gland)

PancreaticEnzymesandFunction

1.Alphaamylase:starchdigestion,secretedinactiveform
2.Lipase,phospholipaseA,colipase:fatdigestion(removes#1,3carbon)
3.Proteases(trypsin,chymotrypsin,elastase,carboxypeptidases):proteindigestion,secretedasproenzymes
4.Trypsinogen*isconvertedtoactiveenzymetrypsinbyenteropeptidase,aduodenalbrushborder
enzyme.Trypsinthenactivatestheotherproenzymesandtrypsinogen(positivefeedback)
*PRSS1mutationsarerelatedtohereditarypancreatitis

StimulationofPancreaticFunctions:

1.Secretin*:stimulatesflowofbicarbonatecontainingfluid
2.Cholecystokinin(CCK)*:majorstimulusforzymogenrelease;weakstimulusforalkalinefluidflow
3.Acetylcholine:majorstimulusforzymogenrelease,poorstimulusforbicarbsecretion
4.Somatostatin:inhibitsreleaseofgastrinandsecretin
*secretedfromduodenum

SecretionRates

Pancreas:
Basalexocrine:0.20.3mL/minupto5mL/minwithmaximumsecretion(i.e.morethangastricH
+
)
Na
+
,K
+
alwaysplasma;
Atlowrates,HCO3,Cl

compositionplasma;
AthighratesHCO3,Cl

reverse

Bile:
10001500mL/day(0.41mL/min);gallbladdercanonlystore60mLoffluid,butcanconcentrate
upto10fold*
*Keepthesenumbersinmindforpatientswithbileleakstoassessnatureofductalinjury,i.e.howmajoran
injury?

Howethanolcausespancreatitis:
1. Pancreaticducthypertrophyampullaryresistance
2. Stimulationofgastricacidsecretionsecretinexocrinesecretion
1+2enzymeextravasation;exacerbatedby
acetaldehyde(byproductofethanol)membranepermeability,and
TGsourceofcytotoxicfreefattyacids
HopkinsGeneralSurgeryManual 98
RansonsCriteriaEthanolassociatedPancreatitis

Initial: Duringfirst48hours:
Age>55 Hctfalls>10%points
WBC>16,000permm
3
BUNincreases>5mg/dL
Bloodglucose>200mg/dL Serumcalcium<8mg/dL
AST>250mg/dL ArterialPaO2<60mmHg
SerumLDH>350mg/dL Basedeficit>4mEq/L
Fluidsequestration>6L

Mortality:
If02signs,then2%
If34signs,then15%
If56signs,then40%
If78signs,then100%
Note:allyoucanreallyconcludeis>3signspoorprognosis(inactuality,prognosisisslightlybetter
todaybecauseofgreatlyimprovedcriticalcare)

Distinguishbetweenedematouspancreatitis(resolves)andnecrotizingpancreatitis(progresses).
Pathogenesis:1
o
celldeathlocalinflammatoryresponsesystemicinflammatoryresponseviaportal
circulationtoentirebody.

CTishelpfulfordiagnosisbecausedualphaseCTallowscomparisonofnoncontrastandarterialphaseto
delineatetheischemicextentoftheprocessand/ortoappreciateextralumenalgas

Antibioticsshouldonlybeusedforsevereepisodes(i.e.>3ofRansonscriteria)
1
st
lineagentisimipenem(crossesblood/pancreasbarrierbest)
2
nd
lineagentisciprofloxin

Operativedebridementif:
1. clinicaldeterioration,despitemaximalmedicaltreatment
2. infectionofnecroticpancreas(airinRP,+pancreaticculture)
3. failuretoimproveafter34weeks
IfgallstonepancreatitisperformcholecystectomywithIOC:
QuickimprovementlapcholeIOCduringindexadmission
Severediseaselapcholeatinterval

Pancreaticascites:
followsductaldisruption;oftencausedbyblunttrauma/pancreatitis
abdominaldistentionwithhighamylasefluid
Rx:nonoperative(NPO,TPN,octreotide)
ifpersists>3weeksERCP+sphincterotomytodelineateanatomyandconsidertranspapillary
stenting;iffailsplanRouxYvs.distalpancreatectomy

Siteofductaldisruptionrelatedtocollection:
DorsalruptureRPcollectioncanbesuckedintochest(=pancreaticpleuraleffusion)
Ventralruptureinsidelessersac,ifnotwalledoffpancreaticascites

HopkinsGeneralSurgeryManual 99
PancreaticPseudocyst

Encapsulatedcollectionofpancreaticfluidformedbyinflammatoryfibrosis(NOTepitheliallining)
1in10afteralcoholicpancreatitis;chronicalcoholicpancreatitisis#1causeinU.S.
Sx:epigastricpain,emesis,fever,weightloss
Signs:palpableepigastricmass;tenderepigastrium;ileus
U/S,CT(goodformultiple)showfluidcollection;MRI/MRCP;ERCP(fortreatment):contrastwill
fillcystifcommunicationwithduct
Ddx:cystadenocarcinoma,cystadenoma,IPMN,solidpseudopapillarytumor,mesentericcyst,
adrenalcyst
Complications:infection,bleedingintocyst(mostcommoncauseofdeath),fistula,pancreatic
ascites,gastricoutletobstruction
Treatment:ittakes6weeks(bydefinition)tomatureandwalloffsoitcanholdsutures;ifitsgoing
toresolvespontaneously(50%will),itwilldosoduringthistime

Mostagreethatifpseudocystis>5cmitshouldbedrained(especiallyifsymptomatic)
SizeISanimportantpredictorofresolution
Internal(surgical)drainageissuccessfulin90%ofcases
External(surgical)drainageisreservedforthinwalledand/orinfectedcysts
Externaldrainageshouldbeusedonlyincasesofsepsis
Endoscopicdrainagemaybeappropriateinthesettingofchronicpancreatitis

SurgicalDrainage:
1.Ifadherenttoposteriorwallofstomach:cystogastrostomy
2.Ifadherenttoduodenum:cystoduodenostomy(rare)
3.Ifnotadherenttoeither:RouxenYcystojejunostomy(drainintoRouxlimbofjejunum)
4.Ifintail:resecttailwithcyst

*ALWAYSbiopsycystwalltoruleoutcysticneoplasia

CysticNeoplasmsofthePancreas

Accountfor<15%ofpancreaticcysticlesions(butincidenceincreasing)

IPMN* MCN Serous

Gender M=F 2:1 0.8:1
Age 70 50 6070
Location Head Tail Uniform
Ductalcomponent Yes Rare No
Malignant 35% 30% Rare
*Associatedwithchronicpancreatitis(andoftenmistakenfor)
Bydefinitionmusthaveunderlyingovarianstroma

EUA+FNAforCEAisprobablymostaccurate(optimizedsensitivity+specificity)measureof
malignancy,BUTresectionalmostalwaysindicatedasitisdifficulttoexcludemalignancyonthe
basisofbiopsies[BruggeWR,etal.Gastroenterology,2004;126:1330]
DonotperformCTguidedpercutaneousbiopsy(oftenundiagnostic,potentialtocausepancreatitis,
bleeding,ruptureofcapsule)

HopkinsGeneralSurgeryManual 100
EndocrineNeoplasmofthePancreas

Seeprevioussectionsongastrinoma,insulinoma,glucagonoma.Ingeneral,pancreatictumorsproducing
ectopichormones(e.g.ACTHproducingtumor)areveryaggressive.

ExocrineNeoplasmofthePancreas

Fourperiampullarymalignantneoplasms:
1. pancreaticductaladenocarcinomaofthehead,neck,anduncinateprocess
2. ampullaryadenocarcinoma
3. periVaterianduodenaladenocarcinoma
4. distalcholangiocarcinoma

Ofthese,pancreaticductaladenocarcinomaaccountsforthemost(7585%)andhasthepoorest
prognosis(seefigurebelow)

[YeoCJ,etal.AnnSurg227:821,1998]

Lethality(death/incidenceratio)ofpancreaticadenocarcinomaisapproximately0.99
1520%ofpatientspresentingwithpancreaticcanceraresurgicalcandidates,theremainderhave
metastaticdiseaseorlocallyadvanced(unresectable)disease
Ofpatientswithpancreaticadenocarcinoma,thesurgicalcandidateshave1020%5yearssurvival
VisualizationoffatplanesaroundSMV/PVarepredictiveofresectability
ThrombosisofSMV/PVisacontraindicationforresection

HopkinsGeneralSurgeryManual 101
Resectable Unresectable

Outcomesforpancreaticcancer
Mediansurvivalfollowingresectionwithpositiveretroperitonealmargin:612months(with
chemoradiation)
Mediansurvivalfollowingstandardpancreaticoduodenectomyforadenocarcinomaofpancreas:
2022months(13.5monthswithoutchemoradiation)
MediansurvivalfollowingreconstructionofPV/SMV:2022months
MediansurvivalfollowingreconstructionofSMA/celiac:610months
Suggestsvenousinvolvementafunctionoflocation,notbiology

Predictorsofoutcomefollowingresection
1. ResectabilityR0,R1,R2(i.e.marginstatus)
2. LNinvolvement
3. Tumorsize
4. Adjuvanttherapy
5. Moleculargenetics(particularlymedullaryvariantwithMSIdobetter)

[FiguretakenfromtalkbyR.Royal,2004]
HopkinsGeneralSurgeryManual 102
Sarcoma

8000cases/yearinUS;1%ofadultcancers
Mesodermorigin
Nopredilectionforsex,age,race
Overall5yearsurvivalapprox50%

MostCommon:Liposarcoma,fibrosarcoma,leimyosarcoma(MFHissortofawastebasketterm),
essentiallynochangeintreatmentorsurvival

Staging(grade,size/depth,metasteses;nothistology):
StageI:lowgrade,<5cmdeepor>5cmsuper,nomets99%OS
StageII:lowgrade,>5cmdeepORhigh<5cmdeep/>5cmsuper,nomets82%OS
StageIII:highgrade,>5cmdeep,nomets/nodes52%OS
StageIV:metasteses(includingnodes)20%OS
Sites:
Lowerextremity32%
Upperextremity14%
Retroperitoneal15%
Viscera16%
Trunk11%
H&N12%

Biopsy:
<3cm,uncomplicatedExcisionalbiopsy
Ifincisionallongitudinal
Coreneedle>>>FNA(notrecommended)

Prognosis:
Grade:low>high
Depth:superficial>deep
Location:distal>proximal;extremity>>RP/visceral

Treatment:

LowGrade
1. NCISurgeryBranchProspectiveRandomizedTrial(excludingRP/viscera):surgery+(XRT6800rad
vs.observation)XRTeffectiveinpreventingrecurrence,butnoeffectonsurvival
2. MSKProspectiveRandomizedTrial:surgery+(brachyvs.observe)nodifferenceinlocalcontrol
orsurvival

HighGrade
Narrow(<1cm)margin5090%recurrence
Wide(>1cm)margin3050%recurrence
Radicalresection(entiretissuecompartment)<20%recurrence

RoleofXRT:

1. NCISBPRT:Wideresection+adjuvantchemo(adria+cytoxan)(XRTvs.observe)p=0.003(0%vs.
22%recurrence),butnosurvivaldifference(p=0.64)
2. MSKPRT:consistentwithabove

HopkinsGeneralSurgeryManual 103
Roleofsystemicadjuvantchemo:SMACMetaanalysis[Lancet1997350:1647]
Adriamycinvs.others
Found:decreasedriskofmets/distantdisease,localrecurrence
BUTnoincreaseinsurvival
OverallHR=0.89(0.761.0395%CI),p=0.12,increasedsurvivalfrom50to54%
Hence,nosupportofadjuvantchemotherapy.
Currenttrendfavorsinductionchemoradiationtoshrinklesionspreoperativelylessaggressive
resections

IncreaseRiskofRecurrence:+margin,previousrecurrence,noXRT;Localrecurrenceisstrongestpredictor
ofsurvival

Predictorsofsuccessformetastesectomy(lung):
1.Numberoflesions(5)
2.Diseasefreeinterval(>1year)

Melanoma

Thicknessofprimarytumor Marginofresection
insitu
<1mm
12mm
24mm
4mm
5mm
1cm
12cmdependingonlocation(2ispreferred)
2cm
2cm

Lesionsofintermediatedepth(14mm)andlesions1mmthatareulceratingorClarkslevelIVorV
shouldreceivesentinelnodebiopsyintheabsenceofclinicallypalpablenodes
[summaryoftrialsinReintgenD,etal.SeminOncol.2004;31:363]

RevisedAJCCStagingforMelanoma:

HopkinsGeneralSurgeryManual 104

[BalchCM,etal.JCO2001,19:3635]

Forpatientswithmelanomaofdepth14mmandpatientswithulceratedmelanomathereisasurvival
benefitassociatedwithelectivelymphnodedissectionvs.observation.[BalchCM,etal.AnnSurgOnc2000,7:87]

Merkelcellcarcinoma:rareskintumorofneuroendocrineorigin.Similartomelanomainthatittypically
appearsinsunexposedareas,andlymphnode(1030%)anddistantsites(2540%)ofmetastesesare
oftenpresent
HopkinsGeneralSurgeryManual 105
Hernia&AbdominalWall

Approximately75%ofabdominalwallherniasoccurintheinguinalregionofwhicharedirect
Malesexperience5xmorethanfemales;inbothgendersdirectaremorecommon
Femoralcanalisboundedby:Coopersligamentinferiorly,theileopubictract(inferiormarginof
transversalisfascia)superiorlyandmedially,andthefemoralveinlaterally
Posteriorviewofinguinalanatomy:

IfstrangulationissuspectedtoOR(donotattemptreduction);opensacpriortoORreductiontoassess
viabilityofsaccontents
Spigelianhernia:inferiortolineasemicircularis(thepointatwhichtheinferiorepigastricarteryenterstherectus
sheath),throughlineasemilunaris;deeptoexternalobliquehencehardtodiagnose;repairall
Petitshernia:inferiorlumbartriangle:iliaccrest,externaloblique,latissimusdorsi
Grynfeltthernia:superiorlumbartriangle:12
th
rib,internaloblique,lumbosacralaponeurosis

[NettersAnatomy,1996]
HopkinsGeneralSurgeryManual 106
TraumaPrinciples

Top3causesofprehospitalmortality
1.Headinjury
2.Hemorrhage
3.Airwayobstruction

Withmassivehemorrhage,themostimportantfactorinpredictingoutcomeisdurationofhypotension

Criticaldecisionforpatientwithheadinjuryiswhetherornotmasslesionispresent

Multipleinjuries,pluswidenedmediastinumdecompressionofmasslesioninheadisstillfirst
priority.
Ifpatientarrivesinshock,withwidenedmediastinumbleedingmostlikelyinabdomen(gothere
first)
IfpatientstablewithwidenedmediastinumCTchest/arterigraphyfirst,butmustRULEOUT
abdominalbleedingpriortothoracotomy

Thetwomajorinjuriesassociateswithwidenedmediastinum(typically>8cm):containedaorticrupture
andvertebralbodyfracturewithassociatedhematoma

Whenassessingcirculationmustdiscriminatebetweenpumpandvolumeproblems:
Pumpproblemsdistendedneckveins(tamponade,tensionpneumothorax,myocardialcontusion,air
embolus)

Finitenumberofsitesofsignificantinternalbleeding:Chest,thigh,abdomen,pelvis,RP

Ribfractures,includingthoseof1
st
and2
nd
ribs,arerelatedtotheMAGNITUDEofdeformation;
ThoracicaortainjuryisrelatedtotheinitialSPEEDofdeformation;hence,notdirectlyrelatedtoeachother

Amnioticfluidonpelvicexamwillbealkaline(deepblueonnitrazinepaper);KleihauerBetke(KB)blood
testdetectsevensmallamountsofmaternalfetaltransfusion

LowCVPisnotagoodindicatorofhypovolemia,ratheritsuseishelpfulwhenhigh(tamponade,tension
pneumothorax)

ZoneI:clavicletocricoid;ZoneII:cricoidtoangleofmandible;ZoneIII:angleofmandibletobaseofskull

Ingeneral:ZoneIIunstablesecureairwaytoOR;ifstablecandosameorconservativeapproach:
carotidarteriogram,bariumswallow,rigidesophagoscopy,bronchoscopy

Brachiocephalictrauma:ZoneIItoORwithoutarteriography;Zone1&3frequentlytreated
conservatively

Patientswithexsanguinatingexternalhemorrhage,expandinghematomas,orneurologicdeficitsairway
OR(nodiagnosticprocedures)

HopkinsGeneralSurgeryManual 107
Bluntcarotidarterytrauma:fewsignspriortoneurologicalchanges;mortalityhigh(25%)andof
survivorshavepermanentneurologicaldeficit.Thelesionsarerarelyamenabletosurgicalrepair
anticoagulationappearstobethemainstayoftreatment

Ingeneral,trytoavoidoperatingonthevertebralartery,evenproximally.Angiography+embolizationis
alwaysthebetteroption.

Carotidarteryligationresultsinneurologicdeficitinonly20%ofadults

UseofrecombinantFactorVIIainbleedingtraumapatients[Boffardetal.JTrauma59;8:2005]
Randomizednearly300patientswitheitherblunt(143eligible)orpenetrating(134eligible)traumato
receiveeither3xplaceboinjectionsor3xrFVIIa(200,100,and100g/kg)inadditiontostandardtreatment
withthefirstdosefollowingthe8
th
unitoftransfusedRBCandsubsequentdosesadministered1and3
hourslater.InblunttraumathetreatmentgrouphadasignificantreductioninRBCrequirementand
massive(>20)transfusionrequirements.Inthepenetratingtraumaarm,treatmentresultedintrends
towardsfewertransfusions,buttheresultsdidnotreachstatisticalsignificance.Bothgroupsexperienceda
trendtowardsreducedmortality.Adverseevents(e.g.thromboembolism)weredistributedequally
betweenallgroups.
[CurrentTherapyofTrauma,4
th
,1999]
HopkinsGeneralSurgeryManual 108
Incisions

Suspectedinjuryto

Incisionforbestexposure
Innominateartery

Rightsubclavianartery

Leftsubclavianartery

Carotidartery

Axillaryartery
Mediansternotomyextensionintocervicalorrightsupraclavicular
incision

Mediansternotomyforproximalvesselinjury;distalsupraclavicular
incisionfordistalinjury

Mediansternotomy+extensionintosupraclavicularincision

Cervicalincision

Innerarmwithpatientsarmawayfromside;infraclavicularincisionmay
benecessaryproximally

Ingeneral:mediansternotomyisalwayssafestbecauseofbetterproximalcontrol;neverhesitatetoresect
theclavicle

PelvicFractures:
Mostcommonassociatedwithhemorrhageare:
1.Butterfly/Straddle:all4pubicrami
2.Openbook:diastasesof>2.5cm
3.Verticalshear:bothanteriorandposteriorelementswithverticaldisplacement>1cm
Ifunstablemustruleoutintraabodominalhemorrhage
Pelvicfractureassociatedwithurethralinjuryin15%ofmales(veryrareinfemales)andbladder
rupturein7%ofpatients

AbsoluteindicationsforurgentoperativerepairinGUtrauma:
1.Avulsionofrenalpedicle
2.Acuteischemiaresultingfromarterialintimalflap
Bloodatmeatus,highridingprostate,anteriorpelvicfracture,orpenetratinginjuryproximaltourethra
requireretrogradeurethrographybeforeFoley(12Frcathwithoutlube1to2cmin2040mLcontrast
in).Inhemodynamicallystablepatientswithoutgrosshematuriaincidenceofrenalinjuryis<1%

PeripheralVascularTrauma
20%ofpatientswithseriousarterialinjurieshavenormalpulsesdistaltoinjuryhenceany
penetratinginjuryinpathofmajorarteryshouldbeinvestigated;ABI<0.9shouldraisesuspicion
Posteriorkneedislocationshouldundergopoplitealarteriographyafterreduction,unlessABI>
0.9
Hardsignsofvascularinjury(pulsedefect,pulsatilebleeding,thrill,bruit,expandinghematoma)
GodirectlytoOR(noangiography);administerheparinimmediately;reversedsaphenousvein
graftisinterpositionalgraftofchoice,butPTFEok
HopkinsGeneralSurgeryManual 109
NeurologicTrauma

GlasgowComaScale(motorisbestprognosticindicatorofoverallneurologicoutcome)

EyeOpening Verbal Motor

4:spontaneous
3:topain
2:toverbalstimuli
1:none
5:oriented
4:disoriented
3:inappropriatewords
2:incomprehensiblesounds
1:none
6:obeyscommands
5:localizespain
4:withdrawsfrompain
3:decorticateposturing
2:decerebrateposturing
1:none

Lesionsclassifiedasfocalandnonfocal:

Focal
epidural/subdural,intraparenchymalhematomas(requireurgentsurgicaldecompressionfor
masseffect)
IndicationsforOR:midlineshift>5cm,ICP>20mmHg,deteriorationinneurofindings
Subdural>>Epidural(3%ofpatientswithsevereheadinjury);subarachnoidrarelycauses
masseffect,butvasospasmisbiggestconcern
Nonfocal
3categories(mildconcussion,classiccerebralconcussion,DAI)
Hypotension(prehospitalandhospital)issinglebiggestpredictorofpoorneurooutcome
anddeath

Tools:CT,ICP,JugularbulbO2saturation(<50%believedtorepresentcerebralischemia),TCD

1995AitkenBrainTraumaFoundationGuidelinesforTreatmentofHeadInjury
(Only3levelonestandardsforpatientsGCS38)
1. NOprolongedhyperventilation[Note:respiratoryalkalosiscausesareflexvasoconstrictionofthe
cerebralbloodvesselsdecreasingintracerebralbloodvolumeandpressure;butbestusedinacute
management]
2. NOprophylacticsteroids
3. NOprophylacticantiseizuremedsbeyond7days

WhogetsICPmonitoring?
1. GCS8+abnormalCT,or
2. GCS8+twoofthefollowingthree:(age>40,MAP<90mmHg,clinicalsignsofelevatedICP),or
3. ANYTBIpatienthavinganinvasiveoperation/intervention

SkullFractures
Inandofthemselvesdonotcauseinjuryorwarrantintervention,butmarkersofdamage
Operateifdepressedand:CSFleak,underlyingtissueinjury,significantdeformity

HopkinsGeneralSurgeryManual 110
CSpineFracture
C1burstfracture(Jeffersons):causedbyaxialloadingstable(ifisolated)treatwithcollar
C2posteriorelementfracture(Hangmans):causedbyextensionanddistractionunstable3monthsin
halo
Odontoidfracture:
TypeI:abovebasestable;
TypeII:atthebaseunstable;<5mmdisplacement3monthshalo;>5mmC1/2fusionor
screwfixation
TypeIII:extendintovertebralbodyhalo

3Columnsdeterminethestabilityofthespine:
1. Anterior:anteriorspinousligament
2. Middle:vertebralbody,posteriorspinousligament
3. Posterior:facet/laminainterface
Instabilityresultswhenatleastareinterrupted.Penetratinginjuryrarelyresultsininstability.

TandLspinefractures(occurbetweenT11andL3):
Fracturesthatinvolvethemiddleorposteriorcolumnsarebydefinitionunstableand,becauseofthe
narrowspinalcanalinthisregion,cancausesevereneurologicinjury
Iffingerspreadingcanbeaccomplishedwithsymmetryandstrength,thereisnocordinjuryabove
C8

CordInjury
MostcommonC6toT1
Iftipofodontiod(dens)is>4.5mmaboveMcGregorsline(hardpalatetolowestpointonoccipital
bone)basilarimpressionlikely
ORforcompression>50%heightofvertebralbodyor>30%narrowingofcanal

NASCIS2Trialdemonstratedthatinpatientswithblunttraumatothespinalcordhighdose
methylprednisolone(30mg/kgbolusfollowedby5.4mg/kg/hourfor23hours),ifinitiatedwithin8hoursof
injury,resultedingreaterneurologicrecovery,whichremainedatoneyear[NEJM322;20,1990]

Afollowupstudyfurtherdemonstratedthat24hourtreatmentwassufficientforpatientsinitiatedon
treatmentwithin3hours,but48hoursteroidtreatmentwasnecessaryforpatientsinitiated38hoursafter
injury[JAMA277;20,1997].

NeurogenicShock
Nottobeconfusedwithflaccidspinalshock
Lossofvasomotortoneinvisceraandlowerextremities;needvolumefirst,peripheral
vasoconstriction(e.g.neo)second.Hypotensionshouldfirstpromptsearchofothercausesofshock
(suchashypovolemia)
Mayseebradycardiaandwarm,perfusedextremities

NexusCriteria
Nofilmsif:
Nointoxication,alert,awake,no MS
Noneurodeficit
Noneckpain
Nodistractinginjury
Normalneckexam
HopkinsGeneralSurgeryManual 111
FocusedAbdominalSonogramforTrauma(FAST)Exam:
Ultrasoundcandetectaslittleas100mLoffreefluidintheperitoneum.Withholdfoleyplacementuntil
FASTisdonetofacilitatebladderview

1
st
View:Subxiphoid,demonstratesalongitudinalcrosssectionoftheheartandpericardialsac

2
nd
View:RUQ,demonstratesasagitalviewoftheliverandright
kidney

3
rd
View:LUQ,demonstratesasagitalviewofthediaphragm,spleen,andleftkidney
(Note:2locationsforfluidaccumulation)

4
th
view:Pelvis,demonstratesatransverseviewofthepelvis

HopkinsGeneralSurgeryManual 112
ChestWallInjuries

Sentinelinjuries:
Firstribfracturecanindicateunderlyingheadandneckinjuryorgreatvesselinjury
ScapularfractureCNSinjuries,pulmonarycontusion
Sternalfracturecardiaccontusion,greatvesselinjury
Bilateralribfracture,lowerribfractureliver,spleen

Flailchest:adjacentribs,eachintwoormoreplacesparadoxicalmovementonrespiration(canbe
overlookedinpositivepressureventilation).Threecomponents:
1.Alteredchestwallmechanics,
2.Underlyingpulmonarycontusion(*mostsignificant),
3.Painreducedtidalvolume
Ifawake,alert,deservetrialofnonintubation,butadequateIVpaincontrol(considerepidural);if
respiratorydistressvolumecontrolledventilation

OpenPneumothorax:Ifthedefectismorethanthediameterofthetracheaoninspirationairwill
preferentiallypassthroughchestwallratherthanairway;initialmanagementiscreatingafluttervalvetype
dressing+chesttubeatsiteremotefromdefect

TrachealInjury:
IfpenetratingexploreviaSCMincision
Patientspresentingwithmassivesubqormediastinalemphysemashouldbesuspectedofhaving
distaltrachealorbronchusinjury;Also,constantbubblingafterchesttubeplacement;Perform
bronchoscopyASAPtoruleouttracheal/bronchialtear
80%oftraumatictearsoccurwithin2.5cmofcarina;AirwayrepairdoneviarightPLthoracotomy

PulmonaryContusion:donotmanifestonCXRuntil>24hours;hypoxiamaybefirstsign;consider
intubationifPaO2<60mmHgon>40%O2orifPaCO2>50mmHgwithnormalHCO3

PulmonaryLaceration*:Thoracotomyindicatedfor:
1.Entirehemithoraxopacified,
2.Shockthatispersistentordevelopsorispersistentashemothoraxisevacuated,
3.Rapidremovalof>1500mLblood,
4.>250mL/hourx46hours,
5.Significanthemoptysis
*ConsidertractotomywithGIAstaplerovertraumapneumonectomy(morepapersthansurvivors)

AirEmbolism:
Asdistributedtoendorgans,smallbubblescauseischemicdamageastheyoccludevesselsofthe
microcirculation;Brainandmyocardiumaremostsensitive;
RCAisanteriorinsupinepatient,hence,receivessubstantialproportionofAEastheyexitaortic
root
PenetratingthoracictraumacausesoftraumaticAE
Cluestoinjury:Chestinjury,withoutheadinjuryyetfocalneurosigns
Treatment:cessationofcontinuedAE;headdown,thoracotomyonsuspectedsidewithhilarcross
clamping;InterventionsthatincreasePaO2,CO,BPenhanceairbubbledissolution
HopkinsGeneralSurgeryManual 113

Fatemboli:longbonefracture;petechia,hypoxia,confusion/agitation;Sudanurinestainforfat

CardiacTrauma:
Penetratinghearttraumahave75%prehospitalmortality(higherforblunttrauma)
RV>LV>RA>LA
Majormorbidityiscoronaryarteryinjury
Presentationoftamponade:extremeanxiety,hypotension,distendedneckveins
Followingthoracotomyandaorticcrossclampingopenpericardium(longitudinallyfrominferior
tosuperior)
FinefibrillationisabadsignandwontconverttocoursefibrillationuntilthepHreaches7.20
s/pbluntcardiactrauma:newmurmurshouldraisesuspicionofvalvularprolapse(mitral,
tricuspid)ortraumaticVSD

EsophagealTrauma:mostcommonsiteiscervical(>80%)
Shouldbesuspectedwhen:
posteriorchestwound,
transmediastinalinjuries,
penetrationsofplatysma,and/or
tracheobronchialtrauma;
Gastrograffincanmissupto15%ofinjuriesandshouldbefollowedwithdilutebarium
Management:
<24hours,stablepatient:primaryclosure,buttressedwithtissueanddrained
>24hours;unstablepatient:Cervicalsimpledrainage;iflargespitfistula;ThoracicclosewithGrillo
(pleural)patch,extensivedebridement,widedrainage

CausticInjuries:scopeonlytofirstareaofburn,notbeyond
FirstDegree(hyperemiaandedema):IVuntilabletohandleownsalivabariumswallowadvancediet
astolerated
SecondDegree(hemorrhage,exudates,ulcerations):asabove,repeatendoscopyin3weekstoruleout
stricture
ThirdDegree(completeobliterationofmucosa,circumulceration,eschar):controversial;consider
esophagectomy
HopkinsGeneralSurgeryManual 114
RetroperitonealInjuryExploration:

HopkinsGeneralSurgeryManual 115
GreatVesselInjury:acutehypotension,suddenCVcollapse,unusualshadowonCXR
Suggestivephysicalsigns:unequalperipheralpulses,steeringwheelcontusiononchest,palpablesternal
fracture
ORindications:initialbloodfromchesttube>1500mL;>200mL/hourx4hours;hemopericardium;
tamponade;expandinghematomaatthoracicinlet;hemorrhagefromsupraclavicularwound
Exposure:ifunstable:leftALthoracotomywithtranssternalextensionintorightchest;
Ifconfirmedthoracicvenacava,ascendingaorta,arch,thoracicinnominate,carotidmediansternotomy
ofbluntaorticinjuriesarrivingtothehospital(20%oftotal80%dieatscene)willhaveanormal
arrivalCXR

DiaphragmaticInjury:occursin15%and45%ofpatientswithstabandGSWinvolvingupperabdomen
andlowerthorax,respectively.
Forpenetratinginjuries:L=Rsidedinjuries(usuallysmalltears),BUTforbluntinjuries:L>5xRsided
lesions(usuallylargertears)

SplenicInjury:mostcommonlyinjuredabdominalorganinblunttraumathatrequirestreatmentduring
celiotomy
RiskofOPSIisgreatestafter1
st
year,butappearslifelong;greaterinchildren
Nonoperativeapproachbetterif:<55,nosubstantialhemoperitoneum,nocoagulopathy,novascularblush
oncontrastCT;Canmanagenonoperativelyifvascularblushpresentifnoextravasationofcontrastand
stablehemodynamics.

LiverInjury:mostcommonlyinjuredorganinpatientswithbluntabdominaltrauma(3040%)
IfdeepvenousbleedingfromoverthedomeoftheliverencounteredgradeVorVIinjurylikely
extendincisionintochestwithoutapplyingtractiononliver;UseHeaneysmaneuver(clampingsupraand
infrahepaticIVC),venovenobypass,oratriocavalshunting
IVcontrastinthegallbladderindicates(abnormal)connectionbetweenbiliaryandvascularsystems
(severalweeksoutfromlivertraumaindicateshemobilia)

Canmanagebothliverandspleenwithangiographyifblushpresentinstablepatient

PancreaticandDuodenalInjury:
0.23%ofblunttrauma,slightlymorewithpenetratingtrauma
90%haveatleastoneotherintraabdominalinjury,withanaverageofthree
Duodenummostcommonsiteofintramuralhematomafollowingblunttraumacanpresentas
highgradeproximalobstruction1272hoursaftertrauma;(assumingstable)obtaingastrograffin
SBFTfollowedbybariumswallow;afterrulingoutotherinjurycanmanagewithNGT/TPN,butif
noresolutionin1014daystoORtoevacuate

OrganInjuryScale:
IHematomaminorcontusionwithoutductinjury
Lacerationsuperficialwithoutductinjury
IIHematomamajorwithoutductinjuryortissueloss
Lacerationmajorwithoutductinjuryortissueloss
IIILacerationdistaltransactionorparenchymalinjurywithductinjury
IVLacerationproximaltransactionorparenchymalinjuryinvolvingampulla
VLacerationmassivedisruptionofpancreatichead
HopkinsGeneralSurgeryManual 116

SelectiveTreatment:
IExternaldrainage
IIExternaldrainage;distalpancreatectomyifdistal
IIIDistalpancreatectomy
IVExtendeddistalpancreatectomy
VResect(ordrain)pancreas,excludeduodenum;considerWhipple

Colon/Mesocolon:
Atlaparotomyexploreallhematomasorcolonwallormesocolontoidentifyoccultperforations
Primaryrepairofcolonicinjuriescanbeperformedunlessfollowing:
>50%circumferentialinjury(i.e.destructiveinjury)
significantassociatedinjuries,ISS>25(i.e.unstable)
peritonitis
significantfecalspillage
hemodynamicinstability

RectalInjuries:3Principles:
1.Formationofaproximal,completelydivertingcolostomy
2.Insertionofpresacraldrainsbetweenanalvergeandthecoccyx
3.Debridementandprimaryrepairoftheinjuryitself,ifitisaccessible
HopkinsGeneralSurgeryManual 117
CriticalCare

SIRS(SystemicInflammatoryResponseSyndrome):atlease2ofthefollowing4(intheabsenceofother
explanation):
1. Hyperthermia(>38
0
Cor100.4
0
F)ofhypothermia(<36
0
Cor94
0
F)
2. Tachycardia(>90bpm)
3. Tachypnea(>20/minorPaCO2<32)
4. WBC>12,000or<4,000permm
3
(or>10%bands)

Sepsis:Knownorsuspectedpresenceofinfection(bacteremia,toxemia,fungemia,viremia)plus2ormore
SIRScriteria

SevereSepsis:Sepsisplusevidenceoforgandysfunction,hypotension,orevidenceofhypoperfusion

Shock:Endorganhypoperfusion.Period.Oftenmanifestedbylacticacidosis,oliguria,mentalstatus
changes,andhypotensionrefractorytofluidadministration.

SepticShock:Severesepsisleadingtoshock

Pathophysiologyofthiscascadeleadingtoshock:
Itreallybeginswithapanendothelialorganfailureasaconsequenceofaninflammatorycascade.
MacrophagesreleaseTNF(itselfadirectmyocardialdepressant)andIL1,whichresultsintwodetriments:
1. IncreasedexpressionoftheadhesionmoleculesCD11,CD18,ICAM1,andICAM2onendothelial
cellsandWBCs,resultinginleukoaggregation.
2. PromotionofNOSynthaseactivity,increasingcirculatinglevelsofNO,whichdoestwothings:
directmyocardialdepression,andvasodilation
Theendotheliumitselfbecomesthetargetorganasbloodflowisshuntedaroundcapillaries(becauseof
obstruction),leadingtopoortissueoxygenation

Otheretiologiesofshock:
1.Cardiogenic
2.Neurogenic
3.Hypovolemic
4.Obstructive
5.Distributive(anaphylaxis)

Catecholamineresponsetoinjuryismaximalat2448hours

CO=HR*(EDVESV)
Generally,COasHR(sinus)upto160/min
Atrialkickprovides1520%ofEDV
AreductioninHctby50%producesan8foldreductioninbloodviscositymechanismwhereby
COinnormovolemicanemia

Asthearterialwaveformpropagatesdistallythesystolicpressureincreasesanddiastolicpressurefalls
slightlysothattheMAPremainsconstantexceptincertaincircumstanceslikerewarmingfromCPBor
duringvasopressoradministrationinsepsis

AorticMAPanddiastolicpressuresareslightlyhigherthandistalpressure;BUTsystolicpressurerises
withdistalpropagation

HopkinsGeneralSurgeryManual 118
PADPreflectsleftatrialpressurewhennopulmonaryvascularhypertensionexists.PADPisusually12
mmHghigherthanPCWPandLApressure;PAOPisnotcommonlysuperiortoPADPforestimatingLAP;
AdifferencebetweenPADPandPAOPof>45mmHgisindicativeofPVR,assumingtovalvular
diseaseexists

CarbonMonoxidePoisoning:fewsymptomsiflevel<10%;mostdeathsassociatedwithlevel>60%
AffinityofCOforHbis240xthatofO2withslowdissociation;T1/2is250mininroomair;with100%O2
T1/2reducedto40minutes

OxygenDelivery,Uptake,andExtraction

I.OxygenDelivery(DO2)

DO2=CO*CaO2, [whereCaO2=Hg(g/dl)*1.34(mlO2/gHg)*SaO2+0.003*PaO2(torr=mmHg)]
=CO*[Bound+Dissolved]
=CO*[1.34*Hg*SaO2+0.003*PaO2] takehomemessage:boundO2iseverything when
consideringdelivery,butitisthedissolved
componentthatisnecessaryfordiffusionto
thetissues

II.OxygenUptake(VO2)

VO2 =CO*(CaO2CvO2)
CO*13.4*Hg*(SaO2SvO2)*10

III.OxygenExtractionRatio

O2ER=(VO2/DO2)*100 [Normally:2030%]

ControlofO2Uptake
VO2 =DO2*O2ER

BelowCriticalDO2(300mL/min/m
2
or4mL/kg/min,butvaryingfrom150to1000inthecriticallyill),VO2
becomesDEPENDENTonsupply,andenergyproductionbecomesoxygenlimited(dysoxia)

AboveCriticalDO2,VO2doesnotvarywithDO2,andisessentiallyconstant

RelationshipbetweenO2saturationandpartialpressure:

whereN=Hillcoefficient2.42.6;P50=PaO2atwhichpointSaO2=50%2426mmHg
HopkinsGeneralSurgeryManual 119
VasoactiveDrugs

Drug Mechanism Action Indication

Amrinone Phosphodiesteraseinhibitor
withpositiveinotropic
effects+vasodilatoractions

increasestrokeoutputwithoutanincrease
instrokework.
similartodobutamine,BUTdoesnot
stimulateadrenergicreceptors(hence,not
attenuatedbyantagonists)
effectivesingletherapyof
lowoutputstatescausedby
systolicfailure.
vasodilatormustbe
adequatelypreloaded
Dobutamine Syntheticcatecholamine
consideredinotropicDOC
foracutemanagementof
severesystolicheartfailure.
Mostly1

dosedependentincreaseinstrokevolume
accompaniedbyadecreaseincardiacfilling
pressure(measuredbywedgepressure)
thesechangesarematchedbyadecreasein
SVR,hence,arterialpressureremains
virtuallyunchanged,buthypotensioncan
occurespeciallywhenloworborderline
volumestatus
goodforlowoutputstates
(rightorleftfailure)
NOTsuitableasmonoagent
forcardiogenicshock
mustbeadequatelypre
loaded
Dopamine Endogenouscatecholamine
servingasa
neurotransmitter
Effectsdependonpatternof
receptoractivation
Receptorprofilechangeswithdose:
Splanchnic
(25g/kg/min)(58)(>10)
cardiogenicshock,and
circulatoryshocksyndrome
associatedwithsystemic
vasodilation(e.g.septic
shock)
Highneurogenicshock
(aboveT3/T4,hypoand
bradycardic)
Epinephrine Endogenouscatecholamine. likeDA,atlowdoes(0.0050.02
g/kg/min);
athighdoes(0.010.1g/kg/min)
severevasoconstriction:>0.1g/kg/min
Blockshistaminerelease
cardiacarrest,pulseless
VT/VF,AS,PEA
severeanaphylacticreaction
goodinchildren
FirstLinein:
1.anaphylaxis
2.RHfailure(massivePE)
3.HeartfailurewithlowBP
(toolowforinotrope)
Vasopressin Endogenoushormone
(ADH)
DirectlystimulatessmoothmuscleV1
receptors,resultinginvasoconstriction
hormonallevels(0.010.03U/min)can
helpweanoffothervasopressors
sepsisrefractoryto
norepinephrine,
phenylephrine.
Norepinephrine Endogenouscatecholamine >agonistoftenresultsinreflex
bradycardia
lowSVR,inneedof
inotropicsupport
drugofchoiceinsevere
septicshock
improvesrenalbloodflow
Phenylephrine Endogenouscatecholamine Selectiveagonist lowSVR(providedadequate
preload);donotusefor
pumpfailure

WhenyouseelowSVRandnormal/highfillingpressuresthink:
1. Sepsis
2. Adrenalinsufficiency
3. Anaphylaxis
4. Neurogenicshock(ifhighfluidsanddopamine;iflowfluidsandphenylepherine)
5. AVfistula(large,central)
HopkinsGeneralSurgeryManual 120
MechanicalVentilation

Distinguishbetweenproblemsofventilationandoxygenation:

VentilationProblems

OxygenationProblems
Apnea:headtrauma,meds(narcotics),spinalcordinjury,OD

Hypoventilation:narcotics,headtrauma,spinalcordinjury,
neuromusculardisease,electrolyteabnormality(PO4),in
adequatepainrelief

AirwayDisease:obstruction(foreignbody,aspiration),COPD

MechanicalProblems:ribfracture(splinting),diaphragmatic
rupture,increasedabdominalpressure
Shunt:atelectasisandcollapse,HTX/PTX,pulmonary
contusion,ARDS,cardiogenicpulmonaryedema

DecreasedInspiredO2:highaltitude,smokefilledrooms,
malfunctioningO2deliverydevices

DiffusionLimitations:sarcoidosis,alveolarproteinosis,
extremehyperdynamicstates

V/QMismatches(mostcommoncauseofhypoxia):PE,
pneumonia,asthma/COPD

Conventionalventilation:I:E(inspiratory:expiratoryratio)of1:2(orupto1:1);
Inverseratioventilation(IRV)spendsmoretimeoninspiration(upto4:1)canfurtheroxygenationby
totalPEEP

PhysiologicPEEPislowlevelPEEP(5cm)tostimulateglotticclosuremechanism(whichiseliminated
byETT)showntoFRC,shuntfraction,andimproveoxygenation
autoPEEPisdefinedasPEEPoccurringatthealveolarlevel,whichisgreaterthanthePEEPgeneratedby
theventilator

Theworkofbreathingatrestconsumes2%oftotalbodyVO2;canincreaseupto50%
ShuntFraction=pulmonaryvenousadmixture=amountofbloodshuntedaroundthelungasafractionof
theCO(measuredattheinspiredO2concentrationrequiredtomaintainoxygenation)

VentilatorInducedLungInjury
Notcausedbyhighpeakairwaypressures,butratherbyalveolaroverdistension,whichstretches
thealveolusbeyonditsmaximumvolumeanddisruptsthealveolarcapillarymembrane,and/orby
openingandclosingofthealveoliwithshearstresscausingendothelialinjury.Peakpressureisa
markerofthis,butapoorone.
Bestmeasureoftransmuralpressureactingtodistendthealveoliduringinspirationistheplateau
pressuremeasuredduringa1secondendinspiratorypause(mustbelessthan40cmH2Otoavoid
lunginjury;andmustbeamodeofventilationthatallowsthismeasurement:IMV,supportmode;
notPS).ARDStrialsshowoutcomebestwhenplateaupressure<30cmH2O,withafewtrials
implying25isbest.

VentilatorAssociatedPneumonia(VAP)
2
nd
mostcommonnosocomialinfection(afterUTI);1
st
inmorbidityandmortality
Within48hourscolonizationwiththeprevalent(usuallygramnegative)organisms;ETTallows
themin,butimpairsthenormalmucociliaryclearancemechanisms
Highestriskduringfirst57days(3%perday),thendays710(2%perday),then1%perday
thereafter[CookDJ,etal.AnnInternMed,129:1998]
BALandquantitativecultureisgoldstandard(colonycount>10
4
cfu/mLindicatesbacterial
pneumonia).[SeeexcellentreviewinDodekP,etal.AnnInternMed,141:2004]

HopkinsGeneralSurgeryManual 121
ARDS:
1.PaO2/FiO2<200
2.PCWP<18 ornoassumptionofCHF
3.Diffuseinterstitialinfiltratesinatleast2quadrants
4.Decreasedcompliance(TV/[PIPPEEP];normal6080cmH2O)

LungVolumes:

Tobin(andYang)Index:Bestobjectivedatatoaidinweaningoffvent:
RSBI=RR/VTwhereVTisinliters

RapidShallowBreathingIndex(RSBI):InTpiecetrial:RR/VT(inLiters)if<80thenlikelihoodof
remainingextubatedat24hoursisabout90%.IfRSBI>105breaths/min/Llikelihoodofremaining
extubatedat24hourswasabout10%.NoneedtoweanifRSBI<80CPAPorTpiece[YangKL,TobinM.
NEJM1991,324:1445]

DeadSpace:

HopkinsGeneralSurgeryManual 122
3reasonsforPaCO2
1. CO2production
2. Expiredvolume(hypoventilation)
3. DeadspaceMostcommonreasonsforthisinclude:
1.PE
2.Rightheartfailure
3.PEEP/autoPEEP
4.Hypotensiveshock(perfusion/ventilation)

IfDeadspace/TidalVolume(VD/VT)>0.6usuallynotweanable;
Anatomicdeadspace(airwaybronchiole)150mL;(inanormaladult2mL/kg)
PhysiologicVD=anatomicVD+anywellventilated/poorlyperfusedalveoli

Duringapnea:PaCO26mmHgduringthefirstminuteand3mmHgperminutethereafter(ifCO2
productionnormalandconstant)

Systematicwaytoidentifyetiologyoflowbloodpressure(considerallvariablesintheequation):

6problemsinthetorsothatmustberuledoutquicklyinanacutelyillpatient

1. Tensionpneumothorax
2. Rupturedaneurysm
3. Cardiactamponade
4. Aorticdissection
5. Myocardialinfarction
6. Pulmonaryembolism
HopkinsGeneralSurgeryManual 123
MostInfluentialRecentTrials/PapersinCriticalCareMedicine(reversechronological):

EvidenceBasedClinicalPracticalGuidelineforthePreventionofVentilatorAssociatedPneumonia
[AnnIntMed141:305,2004]
Theseguidelinesprovideexcellentevidencebasedrecommendationsforthepreventionandtreatmentof
VAP.Recommendationsincluded:orotrachealintubation,useofclosedsuctionsystem,heatandmoisture
exchangers,andsemirecumbentpositioning.Treatmentsnotrecommendedincluded:useofsucralfate,
useoftopicalantibiotics.Becauseofconflictingand/orinsufficientdatanorecommendationsweremade
about:chestPT,timingoftracheostomy,pronepositioning,prophylacticIVantibiotics.

EliminatingCatheterRelatedBloodstreamInfectionsintheIntensiveCareUnit
[CritCareMed32;10:2014,2004]
AprospectivecohortcontroltrialinasingleinstitutionICUaimedateliminatingCRBSIbyimplementing
multifacetedinterventionsincluding:handwashingbeforegloving,usingoffullsteriletechnique,and
chlorhexidaneprep.ThisstudyshowedadecreaseinCRBSIratefrom11.3/1000catheterdaysto0/1000
days,whichwasextrapolatedtoprevent43CRBSIs,8deaths,andover$1.9million

AComparisonofAlbuminandSalineforFluidResuscitationintheIntensiveCareUnit
[NEJM350;22:2247,2004]
Amulticenter,randomized,doubleblindedtrialwhichcompared28dayoutcomesofpatientintheICU
whowereadministerednormalsalineor4%albuminforresuscitation.3500patientswererandomizedinto
eacharmandtherewerenodifferencesfoundindeaths,organfailure,numberofdaysspentinICU,
numberofdaysinhospital,requirementsformechanicalventilation,ordaysofrenalreplacement.

Comparisonof8vs.15DaysofAntibioticTherapyforVentilatorAssociatedPneumoniainAdults
[JAMA290;19:2588,2003]
Aprospective,randomized,multicenter,doubleblindedstudytodetermineif8daysofantibiotictherapy
isaseffectiveas15daysinpatientswithmicrobiologicallyprovenVAP.Thepatientstreatedfor8dayshad
similarratesofmortalityandrecurrentinfections.However,inpatientswithnonfermentinggram
negativebacilli,includingPseudomonasaeruginosa,higherratesofrecurrentpulmonaryinfection(40.6%vs.
25.4%)wereseen.

EffectofTreatmentwithLowDoseofHydrocortisoneandFludrocortisoneonMortalityinPatientswith
SepticShock
[JAMA288;7:862,2002]
Aplacebocontrolled,randomized,doubleblind,multicentertrialtoassesstheroleoflowdose
corticosteroidsinthemanagementofpatientsinsepticshockwithrelativeadrenalinsufficiency.Over300
patientswerestimulatedwithcorticotripinandresponders(appropriatestimulation)andnonresponders
(inappropriatestimulation)wererandomizedtoreceiveeithersteroids(hydrocortisone50mgq6+
fludrocortisone50gqd)orplacebo.Amongstnonresponderstherewerestatisticallyfewerdeaths(53%
vs.63%)andstatisticallylesstimespentonvasopressorsinthesteroidtreatmentgroup.Amongst
responderstherewerenodifferencesbetweensteroidandplacebotreatments.

HopkinsGeneralSurgeryManual 124
IntensiveInsulinTherapyinCriticallyIllPatients
[NEJM345;19:1359,2001]
Aprospective,randomized,controlledstudyinvolvingmechanicallyventilatedpatientstoevaluatethe
impactoftightglucosecontrolincriticallyillpatients.Over1500patientswererandomizedreceiveeither
tightglucosecontrol(maintenanceofbloodglucosebetween80and110mg/dL)orconventionalglucose
control(insulinonlywhenbloodglucose>215mg/dL;maintenancebetween180and200mg/dL).At12
monthsintensiveinsulintherapyreducedoverallmortalityfrom8%to4.6%(p<0.04).Inadditionto12
monthmortality,intensiveinsulintherapyalsoledtodecreasedinhospitalmortality,bloodstream
infection,acuterenalfailure,andredcelltransfusionrequirements.

EfficacyandSafetyofRecombinantHumanActivatedProteinCforSevereSepsis
[NEJM344;10:699,2001]
Arandomized,doubleblinded,placebocontrolled,multicentertrialevaluatingtheuseofrecombinant
activatedhumanproteinCinthetreatmentofseveresepsis.Nearly1700patientswithSIRSandorgan
failureduetoacuteinfectionwererandomizedtoeithertreatment(24g/kg/hrrecombinantactivated
proteinCfor96hours)orplacebo.Themortalityintheplacebogroupwas30.8%vs.24.7%inthetreatment
group.Therewasanabsolutereductionintheriskofdeathof6.1%(p=0.005).Theincidenceofserious
bleedingwashigherinthetreatmentgroup(3.5%vs.2.0%,p=0.06).Thisstudyisnoteworthyinthatitisthe
firstagent(ofcountlessagents)toshowadecreasedmortalityinsepticpatients.

DailyInterruptionofSedativeInfusionsinCriticallyIllPatientsUndergoingMechanicalVentilation
[NEJM342;20:1471,2000]
Arandomized,controlledtrialinamedicalintensivecareunitinvolving128patientsreceivingmechanical
ventilationandcontinuousinfusionsofsedatingdrugs.Inthetreatmentgroupthepatientswereawaken
dailybytemporarydiscontinuationofthesedatives.Inthecontrolgroupthesedationwasonly
discontinuedatthediscretionofthetreatingphysician.Themediandurationofmechanicalventilationin
thetreatmentgroupwas4.9daysvs.7.3daysinthecontrolgroup(p=0.004)andthemedianlengthofstay
intheICUwas6.4daysvs.9.9days(p=0.02).Therewerealsofewerdiagnosticstudiestoassesschangesin
mentalstatusinthetreatmentgroup(9%vs.27%,p=0.02).

LowDoseDopamineinPatientswithEarlyRenalDysfunction:APlaceboControlledRandomisedTrial
[TheLancet356:2139,2000]
Over300patientswererandomizedinaplacebocontrolled,doubleblindedstudytoreceiveeitherplacebo
orrenaldosedopamine(2g/kg/min)viacontinuousinfusionuponadmissiontoanICU.Patientswith
preexistingrenaldysfunctionwereexcluded.Useofdopaminedidnotconferanadvantageinpeakserum
creatinine,needforrenalreplacement,lengthofstayinICU,oroverallhospitalstay.Thisstudywas
essentiallythefinalnailinthecoffinofthedebateoverthemythofrenaldosedopamine.

VentilationwithLowerTidalVolumesasComparedwithTraditionalTidalVolumesforAcuteLung
InjuryandtheAcuteRespiratoryDistressSyndrome
[NEJM342;18:1301,2000]
ThistrialrandomizedpatientsacrossmultiplecenterswithacutelunginjuryandARDStoreceiveeither
traditionalventilatorytidalvolumesof12mL/kg(withplateaupressuresupto50cmH2O)orlowtidal
volumesof6mL/kg(withplateaupressuresupto30cmH2O).Thetrialwasstoppedafter861patients
wereenrolledbecausemortalitywaslowerinthelowtidalvolumegroup(31.0%vs.39.8%,p=0.007)andthe
numberofdayswithoutventilatoryusewasalsolower.

HopkinsGeneralSurgeryManual 125
AMulticenter,Randomized,ControlledClinicalTrialofTransfusionRequirementsinCriticalCare
[NEJM340;6:409,1999]
Thismulticenterstudyrandomizednonbleeding,euvolemic,criticallyillpatientswhohadaHb
concentrationof9.0g/dLwithin72hoursofadmissiontotheICUtooneoftwotransfusionstrategies:
Liberaltransfusions:transfusionwasinitiatedwhenHbconcentrationfellbelow10.0g/dLandwas
subsequentlymaintainedbetween10.0and12.0g/dL
Restrictivetransfusion:transfusionwasonlyinitiatedwhenHbconcentrationfellbelow7.0g/dL
andwassubsequentlymaintainedbetween7.0and9.0g/dL
Overall,the30daymortalitywassimilarbetweenthetwogroups.However,amongstpatientswith
APACHEIIscore20(i.e.lessill)mortalitywaslowerintherestrictivegroup(8.7%vs.16.1%,p=0.03),as
wasthecaseinpatientsyoungerthan55(5.7%vs.13.0%,p=0.02).Therewasnodifferenceamongstpatients
withclinicallysignificantcardiacdisease(20.5%vs.22.9%).

AProspectiveStudyofIndexesPredictingtheOutcomeofTrialsofWeaningFromMechanical
Ventilation
[NEJM324;21:6170,1991]
Thisstudyevaluatedanumberofindexesdeterminedfrom36patientssuccessfulorunsuccessful
extubationsandprospectivelyappliedthemtoacohortof64patientsinanefforttopredictsuccessful
extubation.Ofalltheparametersstudied,therapidshallowbreathingindex(RSBI,affectionatelyreferred
toastheTobindespitethefactthatKarlYangsharedauthorshipwithMartinTobinonthislandmark
paper)definedastheratioofrespiratoryfrequency,f,totidalvolumeinliters,Tv,wasthemostaccurate
predictorofsuccess(RSBI<80)orfailure(RSBI>105)ofextubation,wheresuccesswasdefinedasnot
requiringintubationat24hours.

HopkinsGeneralSurgeryManual 126
Hemostasis&Transfusion

Threereactionsmediatetheinitialhemostasisresponsefollowingvascularinjury:
1. Vascularresponsetoinjury(injuryexposessubendothelialcomponentsandinduces
vasoconstrictionindependentofplateletfunction)
2. Plateletadherenceandaggregation
3. Generationofthrombin

Aspirin,indomethacin,andmostotherNSAIDsblockformationofPGG2andPGH2resultingindecreased
plateletaggregation

Normalbleedingtimeis57minutes.Thevalueofthebleedingtimeinclinicalevaluationisvery
limited.Itcanbenormalinpatientswithplateletdisorders,eventhosewhohavetakenaspirin,andcanbe
prolongedinsubjectswithnormalhemostasis.Therefore,itcannotbetrusted.Muchofthelimitationis
probablyrelatedtotechnicalissues,suchasthedepthofthecut,thevascularityofthecuttissue,etc.Also,
thenormalrangeislogarithmicallydistributed,makinginterpretationof712minuteBTsimpossible.

PTandPTTonlyelevatewhenfactorsreducebelowapproximately20to40%ofnormal(varieswith
theindividualfactorandwiththeindividuallaboratorymethods/reagents.Generallythetestsare
adjustedtobecomeabnormalwhenanyofthefactorsisinarangethatmightnotsupportnormal
hemostasis.AverycommoncauseofaprolongedaPTTinapatientwithanegativebleedinghistory
isalupusanticoagulant,alaboratoryartifactnotassociatedwithableedingtendency.)
20%ofnormalisusuallysatisfactoryforgeneralhemostasis,but>50%formajorsurgery

Preoperativeevaluation:
Ifapatienthasapositivebleedinghistoryandrequiresminorsurgery:PT,PTT,BT,fibrinclot
solubility
Ifapatienthasapositivebleedinghistoryandrequiresmajorsurgery:PT,PTT,BT,fibrinclot
solubility,plateletfunctionstudies,FVIIIlevels,FIXlevel,alpha2antiplasminlevel

Asarule:

1unitplateletsfor2unitsRBC.Foratotalbloodvolumereplacement,expectplateletcountof250,000to
dropto80,000.

1mgprotaminerequiredforevery100Uofheparin(upto100mgtotal,or50mgover10min).IftheaPTT
ismeasurable(i.e.,lessthan2minutes),theplasmaconcentrationofheparinshouldbelowenough(i.e.,<1
U/mL)that2030mgprotaminewillbeveryeffective.However,theprotaminemaybeclearedbeforethe
hepariniscompletelygone.Soanotherdosemayberequiredinanhourortwo.

ClottingFactors(seefigurebelow):
Intrinsic(PTT):exposedcollagen+XIIXIIXX,whichactivatesthrombinfibrin
Extrinsic(PT):TF+VIIactivatedXthrombinfibrin
Note:Xiscommontoboth
VIIIisonlyfactornotsolelymadeinliver(madebyendothelialcells)

HopkinsGeneralSurgeryManual 127
BleedingDisorder

VonWillebranddiseaseisthemostcommoninheritedbleedingdisorder(1%ofpopulation;AD)
symptomaticbleedingin1/1000
longPTTandbleedingtime(usually)
associatedwithvariabledeficienciesinbothvWFandfactorVIII;plateletdefectisalsopresent
(althoughthisiscalledplatelettypevWd,itisdifferentfromtheothertypesbecausethedefectis
intheplateletmembrane,notinthevWf).
+Ristocetintest(Ristocetincofactor[i.e.,vWf]activityisthelaboratorytestforvWfactivity,as
opposedtoantigenlevel.)
giveDDAVP(releasesintracellularstoresofvWF)forTypeI(lowvWF)(Theeffectonlylastsfor<
12hours.Repeatdosesmaybelesseffective.)(vWfconcentratesareavailablewhenextended
replacementisneeded.ThesearenotthesameasstandardfVIIIconcentrates,whichcontainvery
little,ifany,vWf.)
givecryoforTypeII(qualitativelypoorvWF)andIII(lowvWF)

HemophiliaA(factorVIIIdeficiency)Xlinkedrecessive;5%normallevelsfVIIIconsideredmild
DONTaspiratehemarthrosis
TxwithfactorVIIIconcentrates(to100%preoplevels)
PTT;normalPT

HemophiliaB(factorIXdeficiency)Xlinkedrecessive
TxwithfactorIXconcentrates
PTT;normalPT(to50%preoplevels)

Glanzmansthrombasthenia:PlateletshaveIIb/IIIadeficiencyaggregation abnormalitiesdueto
decreasedfibrinogenbinding.Extremelyrare.

BernardSoulier:PlateletshaveIbdeficiencyadherencetoexposedcollagenvonWillebrandfactor.
Extremelyrare

HypercoagulableStates

APCResistance:mostcommoninheritedhypercoagulablestate;AD;90%associatedwithFV(Leiden)
mutation5%prevalenceinCaucasianpopulations,muchlessinothers.SpontaneousDVTtypically
onlyoccurinthrombophilicfamilies,whoprobablycarryotherprothromboticgenesinadditiontoFVL.In
thegeneralpopulation(whereFVLislikelytobetheonlyprothromboticgeneinmostindividuals)FVLis
rarelyassociatedwiththrombosis.

ATIIIDeficiency:rare,1/5000;dontrespondtoheparinunlessgivenFFP(toreplaceATIII);canttreat
DVTwithoutgivingFFPThemostcommonformsofATdeficiencyareidentifiedbecausetheAT
moleculedoesnotbindheparinnormally.Theseactuallyarenotassociatedwithanincreasedriskof
thrombosis.SpecializedtestsarenecessarytoidentifytheindividualswiththedangerousformofAT
deficiency.
HopkinsGeneralSurgeryManual 128
LupusAnticoagulant:antiphopholipidAbs;dx:longRussellsvipervenomtime;longPTT;confirmedby
assaysthatdemonstratethedependenceoftheanticoagulantactivityupontheconcentrationof
phospholipidpresent.

HIT:Heparininducedthrombocytopenia,duetoanantibodytothecomplexofheparinandplateletfactor
4,whichissecretedbystimulatedplatelets.Typicalonsetafter510daysofheparin,earlierifrecentprior
heparinexposure.HalfofHITpatientswilldevelopthrombosiswithin30daysunlesstheyaretreatedwith
nonheparinanticoagulants.Whiteclottreatwithhirudinorargatroban(directthrombininhibitor)or
danapariod(indirectthrombininhibitor);dextranisnotsufficientfortreatingclotsresultingfromHIT

Foreachincorebodytemperatureby1
0
Cbloodviscosityby23%

Transfusions:
Bankedbloodhas2,3DPGleftshift(holdsO2tightly)
Risks:CMVhighest;HIV:1:500,000;HepatitisC:1:30,000150,000

HeparinbeforeCoumadin

Heparinmustbegivenfor3to4daysbeforecoumadinwhenanticoagulatingpatientstoprotectagainst
coumadinskinnecrosisiftheyhaveATIII,ProteinC,orProteinSdeficiency.
ForyearscardiologistshavestartedCoumadinwithoutheparinandnotrecognizedanyproblem,
presumablybecausesignificantproteinCandSdeficiencyaresorare.However,Coumadinaloneis
definitelyinadequate/deleteriousforthetreatmentofacutethrombosis.Coumadinandheparincanbe
startedtogether,sincetheeffectofCoumadindoesnotappeartill24dayslater,afterthepatientshould
havebeentheratpeuticallyanticoagulatedwithheparinforseveraldays.Itisespeciallyimportantthat
patientswithHITnotstartCoumadinuntiltheyhavebeentreatedwithanonheparinparenteral
anticoagulant.
ALLpatientswiththrombosistoreceivecoumadinshouldreceiveheparinfor34daysbecausethehalf
lifeoftheanticoagulationfactor,proteinC,ismuchshorterthanthevitKprocoagulantfactors(II,IX,X).

[GeertsWH,etal.,2001Chest119:132S]

HopkinsGeneralSurgeryManual 129
HopkinsGeneralSurgeryManual 130
Metabolism

Anumberofvitalareasofthebody(brain,renalmedulla,RBC,WBC,peripheralnerves)areglycolytic
tissues(requireaglucosesourceofenergyformetabolism)andareunabletoutilizefattyacids.

Whenthelimitedglycogenstoresaredepleted,thisisaccomplishedbygluconeogenesisandrecycling
incompletelymetabolizedglucose.Primarysourcesofgluconeogenesisare:

1. Aminoacids,derivedfromthebreakdownofmuscleproteins,
2. Glycerol,derivedfromthebreakdownoftriglyceridesinadiposestores

Intraumathehormonalmilieuresultsincatabolismofproteinstoresbeyondthatnecessaryforenergy
needsalone
Instarvationbodyattemptstoconserveproteinwastingbyadaptingtoallowutilizationoffattyacids
andketonesforfuelbynonglycolytictissues
Inprolongedfastingbraincanactuallyuseacetoacetateandhydroxybutyrateinplaceofglucose

Lactateandpyruvate(derivedfromincompleteglucoseutilization)canberecycledintoglucoseviaenergy
providedbyfattyacidoxidation(theCoricycle)

Latestarvationshiftfromlivertokidneyastheprimarysourceofgluconeogenesis(sincealanineis
depletedfromtheliver)

Hemochromatosis:
ExcessiveFeabsorptionfromgutafflictsheart,liver,pancreas,pituitary
EarliesttesttobecomeabnormalisFesaturationtest

WilsonsDisease:
AR
defectincoppermetabolism
mostimportantlabfindingiscerulosplasminlevel(<20mg/dL)
livercopperstoreselevatedonbiopsy
HopkinsGeneralSurgeryManual 131
TransplantSurgery

I.TypesofRejection:

1.Hyperacute:preformedantidonorAb.Destructionin2448hours.Rarelyoccurswithpresentday
crossmatchingtechniques.

2.Accelerated:asabove+memoryTcellsinhost.Rejectionwithin5days

3.Acute:Tcellmediated.Mostcommon.Weekstomonths

4.Chronic:usuallyhumoralresponse.Monthstoyears.Currentlynocure.

II.RejectionProphylaxis,prevention,treatment:

Corticosteriods(Prednisone):blockcytokineproduction(IL1,2,3,6,TNF)

Cyclosporin(Neoral):selectivelyinhibitsIL2secretionandproliferationofTcells(calcineurin
inhibitor)

MycophenolateMofeil(Cellcept):inhibitinosinemonophosphatedehydrogenase,(denovopurine
synthesis)causingselectiveantiproliferativeeffectofTandBcells

Tacrolimus,FK506(Prograf):inhibitionofcalcineurindependentsignaltransductioninTcells,
inhibitingcytokineproduction

Sirolimus,(Rapamycin):blocksCa
++
dependentcytokinemediatedsignaltransduction(blocksthe
TORprotein,whicharrestscellinG1)preventingproliferationofTcells

Azathioprine(Imuran):inhibitsDNAsynthesisandconsequentTcellactivation

IL2Inhibitors(Zenapax,Simulect):monoclonalAbsagainstIL2receptors;usedasinduction
therapy

CD3Inhibitors(OKT3):murinemonoclonalAbstoCD3receptoronTcells

Thymoglobuline:rabbitpolyclonalAbtomultipleTcellreceptors.Usedforbothinductionand
rejectiontreatment

Longtermeffectsofsuccessfulsimultaneouskidney/pancreastransplantare:
1.Stabilizationofretinopathy
2.Reducedriskofdiabeticnephropathy
3.Improvementinnerveconductionvelocity
4.NoreversalofCADorPVD

PosttransplantDMisseenin520%ofrenaltransplantrecipients.Steroids,cyclosporine,FK506areall
diabetogenic

HopkinsGeneralSurgeryManual 132
CompletelymismatchedHLA(0/6)LRRTdoesbetterthancompleteHLAmatch(6/6)cadavericischemic
timeandqualityoforganaremostimportantdeterminantsofgraftsurvival

BKVirusisanimportantfactorassociatedwithgraftnephropathy.Prevalentin90%ofpopulationand
resultsinnephropathyin18%oftransplantrecipients(byboutsofrejection,needforrejection
treatment(vs.IS),+donortorecipient);noadequateantiviraltreatment;insteadmustimmune
suppression,inparticularMMF

PostTransplantLymphoma

Lymphomais10100xmorecommonintransplantpatientsthangeneralpopulation(Rangesfrom
1%incidenceinkidney;45%inheart/lungpatients);especiallyseeninCNS
UsuallyNHLBcelllymphomarelatedtomalignanttransformationofEBV
Reduceorwithdrawimmunosuppression(lifebeforegraft)
Highdoseacyclovirmaybeeffective;conventionalchemotherapygenerallynoteffective

MELD(ModelforEndstageLiverDisease)Criteriaforliverfailure*

Score=3.8*ln[bilirubin(mg/dL)]+9.6*ln[Cr(mg/dL)]+11.2*ln[INR]
[Hepatology2001;33:464470]

*Formulapredictstheriskofdeathin3months;averagescoreformostpatientsbeingtransplanted
currentlyis15;additionalpointsgivenfortumorssuspectedorconfirmedtobeHCC

AcuteFulminantHepaticFailure:theappearanceofacuteliverdiseasewithhepaticencephalopathyinless
than8weeksinanindividualwithoutpreviouslyknownliverdisease.

StageI:Prodrome
StageII:Impendingcoma(5070%spontaneousrecovery)
StageIII:Stupor(4050%survival)*
StageIV:Deepcoma(<20%survival)*
*lactuloseoflittlebenefit

KingsCollegeCriteriaforacutefulminantliverfailurerequiringtransplant

AcetaminophenToxicity

Nonacetaminophentoxicity
pH<7.30afterresuscitation,or

INR>6.5,
Creatinine>3mg/dL,and
EncephalopathyIIIIV
INR>6.5,or3/5below:

Age<10or>40
Druginducedorcryptogenic
etiology
Jaundice>7daysbefore
encephalopathy
INR>3.5
Serumbilirubin>17.5mg/dL
HopkinsGeneralSurgeryManual 133
Upperlimitsofacceptablecoldischemictimes:

Heart: 6hours
Lung: 46hours
Liver: 24hours
Kidney: 48hours
Pancreas: 2448hours

Warmischemictimemustbelessthan60minutes

Hepaticarterialthrombosisismaincauseofimmediategraftlossfollowinglivertransplant:
35%inadults
58%inchildren

HCCpatientsarecandidatesforlivertransplantprovided

:
1.Asingletumor<5cm,or
2.Uptothreetumorsindividually<3cm

Milancriteria

HepatorenalSyndrome

10%ofhospitalizedpatientswithcirrhosisandascitesdevelop
progressiveoliguriaCr,CO,BP
similarlaboratoryfindingstoprerenalazotemia(UOP<500mL/24hours,UNa<10mEq/L,Uosm>
Posm)
physiology:splanchnicvasodilation(associatedwithNO)SVRrenalperfusion
onlyeffectivetreatmentishepatictransplantationrenalfunctionusuallyreturnstonormal
HopkinsGeneralSurgeryManual 134
Nutrition

EnergyCapacity:(1calorie=energytotake1mLwaterfrom14.515.5
0
Cat1atm)
Fat:9kcal/g
Protein:4kcal/g(butaqueous,soonly12kcal/gwhenutilized)
Carb:3.4kcal/g

RQ=ratioofCO2producedtoO2consumed=1.0forcarbs;0.7forfats;>1forproteins

EssentialAminoAcids:2L,2T,VIP&Me(Leucine,Lysine,Threonine,Tryptophan,Valine,Isoleucine,
Phenylalanine,&Methionine)

[N]Balance =[N]In[N]Out,where
[N]In =[gprotein/6.25gproteinpergN]
[N]Out =[UUN(mgN/100mLurine)*1000mL/L*24hoururinevolume*gN/1000mgN+3]

BranchedChainAminoAcids:leucine,isoleucine,valine(metabolizedinmuscle;allessential)

AromaticAminoAcids:tyrosine,tryptophan,phenylalanine(essential)

Glutamineis#1AAinbody;mostrapidlyusedinstress;fueloftheenterocytes(whendepletedbrush
borderbreakdown);theadditionofglutaminetoenteralorparenteralfeedsmaysepsis[HoudijkAP,etal.
Lancet1998;352:772]
Hydroxybutarate:fuelofcolonocyte
Arginine:mostimportantforimmunefunction

InhepaticfailureMinimizearomaticAA;givebranchedchainonly
InrenalfailuregiveessentialAAonly

FattyAcidMetabolism:
mediumchainFAcanbeabsorbeddirectlyviaportalblood,hencebypassingthelymphaticsystem
longchainFApoorlytoleratedbypatientswithcompromisedgutfunction;mediumchainbetter,since
absorbeddirectly

ThreeMainformsofFatarefoundinthebody:
1. Glycerides(9598%ofbodystores),essential(seebelow)ornonessential;mostdietarysourcesare
medium(6C)andlong(>11C)
2. Phospholipids(mainlyincellmembranesandmyelinsheaths)
3. Sterols,comprisedprimarilyofcholesterol

EssentialFattyAcids:(unsaturatedbondwithinthelast7carbonsoftheFAchainatthemethylend)
linoleic(TPNmostlyconsistsofthis),linolenic,arachidonic;canNOTbesynthesizedbyhumans

6polyunsaturatedfats(linoleic)precursorsforPGsandleukotrienes

Fatdigestion:micellestoenterocyteschylomicronstolymphatics(tojunctionLIJ/subclavian)

HopkinsGeneralSurgeryManual 135
EnergyStorage:

Fats:25%BW=fat;soif70kg17kgfat160,000kcal
Carbs:circulating80kcal;Liverglycogen300kcal;
Muscleglycogen600kcal(exhaustedin24hours)
Proteins:12kg48,000kcal;butnoaccessunlesslatestarvation
(MainadvantageofdextroseinIVFistoobviatetheneedforproteincatabolism)

glucose+(fructose+galactose)40%Liverglycogen+60%Muscleglycogen

NonproteincalorietogmNitrogenratioof150:1generallyappropriate(bothadultsandchildren)

*Patientswithmajorburn(>25%TBSA)havegreatestcaloricrequirements

AssessingNutritionalStatus:

Albumin:18dayT
Prealbumin:24hourT
Retinolbindingprotein:12hourT(mostsensitive)

Injuredpatientscanmaximallyoxidizeglucoseat56mg/kg/min(abovethisosmoticdiuresis,
respiratoryquotient)

Remember:MetabolicAlkalosisrequireK
+

Marasmus=depletionofbodyfat;relativesparingofvisceralprotein(simplestarvation)
Kwashiorkor=acutevisceralproteindepletion(sparingoffat;acutelyillpatients)

Deficiencies:
Phosphorus:weakness,paresthesias
Zinc:perioralrash,alopecia,poorwoundhealing,impairedimmunity,changeintaste
Copper:anemia,neutropenia,pancytopenia
Iron:anemia
Linoleicacid:dermatitis,alopecia,blurredvision,paresthesias
Selenium:cardiomyopathy,weakness,alopecia
VitaminA:nightblindness,skinkeratosis
Chromium:glucoseintolerance(relativediabetes),peripheralneuropathy
Biotin:alopecia,neuritis

HopkinsGeneralSurgeryManual 136
Fluids&Electrolytes

Sodiumconcentrationmustbecorrectedby23mEqper100mg/100mLelevationinbloodglucoseabove
100[i.e.asBGNa
+
]

Gastriclosses(vomiting)usuallyrequirehypercholoremicreplacement
Postpyloriclossesrequirebalancedsaltsolution(exceptpancreaticfistula,whichrequirehigh
HCO3replacement)
PatientswithGIlossesinitiallyloseisotonicfluidbutthebodyalwaystriestoprotectvolume
status(evenattheexpenseoftonicity)

InsensibleLosses:
Skin>Lung:total600900mL/day
0.9%NaCl=9gmNaClperL

HYPOMg
++
andCa
++
bothhaveHYPERexcitability:reflexes,tetany
CannotcorrectCa
++
withMg
++
sinceMg
++
inducesskeletalresistancetoPTHandmayimpairPTH
synthesis

Prolongedvomiting:resultsinhypokalemia,hypochloremia,metabolicalkalosis;earlyurineis
alkalineBUTasNa
+
isconservedH
+
/K
+
arelostwithHCO3resultinginparadoxicalaciduria

Note:ThemostimportanttreatmentforhyperkalemiaisCa
++
(vs.insulin,HCO3,etc.)becauseitistheonly
agentthatactuallystabilizesthemyocardium

MechanismsofDiarrhea:
OsmoticDiarrhea:accumulationofpoorlyabsorbedsolutesinlumensecretionofH2Ointolumen
SecretoryDiarrhea:excessiveelectrolytesecretion(toxins,neuroendocrinetumors)stimulatecAMP
production
InhibitionofAbsorption:unabsorbedfreefattyacidsorbilesaltsdecreasedH2Oabsorption

Sweat:normallyhypotonic,butcanapproachisotonicityduringperiodsofhighsecretion;Na
+
secretion
parallelsCl

(both<plasma);K
+
approachesplasmaconcentration;ureaandNH3>>plasmaconcentrations
HopkinsGeneralSurgeryManual 137
RenalPhysiology

Kidneycantolerateischemiaupto15minuteswithoutadverseevent
1590minutesproducesvaryingdegreesofchronicdamage
>90minutesusuallyirreversibledamage

Inresponsetorenalbloodfloworpressurejuxtaglomerularapparatusreleasesrenin,whichinteracts
withthe2globulineangiotensinogen(synthesizedintheliver)toproduceangiotensinI.
Inthelung,angiotensinIangiotensinII(halflife:4minutes)increasesBPbytwomethods:
1. directvasoconstrictorproperties
2. stimulatingthereleaseofaldosteronefromtheZGoftheadrenalcortex(Na
+
andH2O
absorptionindistaltubules)

3reasonsforcontraction(metabolic)alkalosis:
1.HypoK
+
(K
+
leavescelltocompensate,HCO3followstomaintainelectricalneutrality
2.Volumedepletion
3.Hyperaldosteronism(diuretics)

RenalFailureIndex=UNa*PCr/UCrif<1prerenaloliguria

70%ofnephronmassisdamagedbeforeBUNandCrlevelsrise
FENa>3andUosm<350mOsm/LrepresentinabilityofrenaltubuletoreabsorbNa
+
andconcentrateurine

FENa=[UNa/UCr]/[PNa/PCr]<1%,BUN/Cr>30,UNa<20allindicatelowvolume

Ifpatienthasreceivedlasixand/orhypertonicNaClduringprevious48hoursFENamaybeoflimited
value.InsteaduseFractionalExcretionofUrea(FEUN):

FEUN=[UUREA/UCr]/[PUREA/PCr]<35%suggestiveofprerenalazotemia

Definitionsoflowurineoutputstate:

Polyuric:>1000mL/24hours Nonoliguric:4001000mL
Oliguric:100400mL Anuric:<100mL

InHighOutputRenalFailure[BUN,u/o>1500/24h]mildmetabolicacidosis:giveNa
+
withlactate,since
Cl

willworsenacidosis

MetabolicAlkalosis
Na
+
Responsive(UCl <10)
vomiting
NGsuction
Na
+
Unresponsive(UCl >20)
mineralocorticoidexcess
HopkinsGeneralSurgeryManual 138
DifferentialDxofelevatedBUNorCr(oneoutofproportiontotheother):

Cr/BUN BUN/Cr
Renalfailure Dehydration
Musclebreakdown +Nbalance
GIbleed
Hepaticfailure

TranstubularK
+
Gradient(TTKG)

[UrineK/PlasmaK,mEq/L]dividedby[Urineosm/Plamaosm,mosm/kg]

Normalis89;maybeupto1withpotassiumloading
IfK
+
ishighandTTKG<7implieshypoaldostoronism

Appropriateresponses
Hypokalemia <3
Hyperkalemia>10

Ifthespecificgravityofurineisnormalkidneyisworking,UNLESSartificialosmolesarepresent
including:
Mannitol
IVcontrast
Highglucoseload
Methanol

HopkinsGeneralSurgeryManual 139
Immunology/Infections

IgG:opsonin(alongwithIgM)tofixcomplement(2IgGsor1IgM),#1inserum;crossesplacenta
IgM:madefirst;levelsaftersplenectomy
IgA:insecretions
IgE:allergicreactions,typeIhypersensitivity
IgD:largelyunknown

Complement:
C3a,C5aandanaphylatocins;C59:MAC(membraneattackcomplex)

Hypersensitivity
TypeI:immediate;IgEmediated;e.g.anaphylaxis
TypeII:cytotoxicreactions;IgGorIgM;e.g.ABO/Rhincompatibility
TypeIII:immunecomplexmediated;depositionofcomplex;e.g.serumsickness,rheumatoidarthritis
TypeIV:delayedtype:TCells(CD4+);e.g.contactdermatitis

HIVPatients
haveincreasedriskofdevelopingNHL(highgradeBcell)andKaposissarcoma

AdvantagesofZosyn

I.vs.3
rd
generationcephalosporins
enterococci,MSSA
pseudomonas,klebsiela
4+anaerobes

II.vs.quinolones
enterococci,MSSA
pseudomonas
4+anaerobes

III.vs.Unasyn
MSSA
E.coli,pseudomonas,otherG
4+anaerobes

IV.Timentin(betterforstenotrophomonas)
enterococci,MSSA
E.coli,pseudomonas,otherG
4+anaerobes

Remoteinfection(e.g.UTI)theriskofsurgicalsiteinfectionbyatleast7%
HopkinsGeneralSurgeryManual 140
Burns

1.Silvernitrate:Broadspectrum,painless,cheap,poorescharpenetration,maycauseelectrolyteimbalance

2.Silversulfadiazine(Silvadine):Painless,noelectrolyteabnormalities,noocclusivedressingrequired,
littleescharpenetration;missesPseudomonas,idiosyncraticneutropenia;goodforsmallburns

3.Mafenide:Penetrateseschars,broadspectrum(butmissesstaph);painandburningonapplication;7%
haveallergicreactions;maycauseacidbasedisturb(metabolicacidosis);agentofchoiceinalready
contaminatedburns;watersoluble

ParklandFormulaforBurns

*AddMaintenanceFluidstobelow:*

1. First24hours:4mL/kg/%BSA.Halfover8hours,thenrestover16hours.
2. Second24hours:Fluidrequirementsare5075%ofthefirstdays.Useweight,electrolytes,UOP&
NGTtodetermineconcentrationandrate.
3. WithholdK
+
forfirst48hoursbecauseoflargetissuerelease.
4. KeepUOP@0.5mL/kg/hour

BurnpatientsinitiallyhavedropinCOthenareHYPERdynamic

BurnWoundInfection

Reducedby:
1.Aggressiveresuscitation
2.Earlydebridement
3.Topicalantibiotictherapy

Toconfirminfectionneedbiopsywithquantitativeculture(10
5
):mustincludenormalandburnedskin
(2x2cmwithnormalunderlyingskin)

HopkinsGeneralSurgeryManual 141
Skin&WoundHealing

Threemajorstagesofwoundhealing:
1.InflammatoryPhase(10minutes2weeks)
2.ProliferativePhase(36weeks)
3.RemodelingPhase(upto1year)

InflammatoryPhase:Hemostasis&Clotformation
PlateletplugmediatedbythromboxaneA2,thrombin,PF4,C5a(mostimportantcomplement)
Monocytesmustbepresentfornormalwoundhealing
Collagenandbasementmembraneproteinsclottingfactoractivation
Vasoconstrictiondecreasebloodlossandallowclotformation(<24hours)
Plateletdegranulation:PDGFandTGF;chemotaxisandproliferationofinflammatorycells
Vasodilation(>2448hours)suppliescellsandsubstratesforwoundrepair

ProliferativePhase:
Formationofmatrixoffibrinandfibronectin
Initiationofcollagenformation
Proliferationoffibroblasts
Growthfactorsfrommacrophagesinitiateangiogenesis(especiallyFGF)
CrosslinkingofcollagenrequiresVitC
Woundisnowascar

RemodelingPhase:
Collagenequilibrium
Increasetensilestrength(abundanceofTypeIcrosslinking)
Diminishingcapillarydensityandfibroblasts

TensileStrengthofWound*:
Early:fibrin
Late:collagencrosslinking
*Tensilestrengthisneverequaltoprewound

10
5
organisms/cm
2
isenoughtoretardwoundhealing

Astimeprogresses:TypeIII(proliferation)collagen andTypeI(mature)
UltimatelytheratioofI:IIIis8:1(i.e.thatofnormalskin)

I Mostabundant,foundinscar
II Incartilage
III Inwouldhealing(lowinEhlerDanlos)
IV Inbasementmembrane
V Foundincornea

HopkinsGeneralSurgeryManual 142
Pharmacology

Cluestodrugoverdose:

1.Eyes
i)Miosis:opiates,org.phos,barbs
ii)Mydriasis:amphetamines,cocaine,antichol,ethanol,mushrooms,LSD
iii)Nystagmus:PCP,phenytoin,ethanol,VPA

2.Mouth
i)Dry:antichol,opiates,SSRIs
ii)Verysalivary:org.phos

3.Skinlookforneedletracks
i)Hot,dry:antichol
ii)Verypink:CO
iii)Verysweaty:org.phos

Pharmacology

P450 P450
Phenobarb INH
Rifampin Cimetidine
PTN Benzos
Carbamazepine Phenothyazines
TMPSMX

Lidocainetoxicity:tinnitus,perioralnumbnessneurosymptomscardiovascularchanges

LocalAnesthetics(2classes)

AminoEsters AminoAmides*
Tetracaine Lidocaine
Cocaine Mepivacaine
Procaine Bupivicaine
Chloroprocaine Etidocaine
*Allhaveanibeforecaine

MalignantHyperthermia:canbegeneticallytransferred;triggeredbyhalogenatedinhalationalagents(1in
250,000);canalsobetriggeredbysuccinylcholine(1in60,000);earliestsignisriseinCO2;hyperthermiaisa
relativelylatefinding;treatwithdantrolene.

Ketamine:doesnotBP,butdoesICP;goodinchildren;avoidinheadtrauma,cardiacdisease

Propofol:rapidonsetandshortduration;idealforpatientswithalteredneuroexamtoallowforfrequent
neuroexaminations;doesBP;doesnotprovideanalgesia

4Componentsof(Informed)Consent:
1. Disclosure
2. Comprehension
3. Competency
4. Voluntariness
HopkinsGeneralSurgeryManual 143
Radiology

Basics
Eachmodalityemitsasourceofenergy.ForconventionalxrayandCTtheenergyemissionisa
photongeneratedbyanelectron(e

)collisionwithitstarget.ForMRItheenergyemissionisa
spinningdipoleofaproton(H
+
)convertedintoradiofrequencycurrent.ForPETtheenergy
emissionisagammarayproducedbythecollisionofapositron(e
+
)andanelectron(e

).
Distinguishbetweenimagingtests(e.g.conventionalCT,MRI,U/S)andfunctionaltests(e.g.PET,
HIDA,U/Sforgallbladderejectiontime,etc.)

IBasicRoentgenogram

DiscoveredbyWilliamRoentgenin1895
Highvoltagecurrent(50120kV)isrunthroughacathodecontainingwirecoil(filament)
providingaconstantstreamofhighspeedelectronstoatungstentargetonananode.
Mostoftheenergyisdissipatedasheat,but1%oftheelectronenergyisconvertedtoxrays,
whicharedeflectedtowardsafilterthatcollimatesthebeamstowardstheanatomicportionof
interestbeforetheypassthroughthebodyofthepatient.Collimatoralsofiltersoutveryhigh
energyandlowenergyxrays
Thedensityofthetissueencountereddeterminesthexrayabsorption:lessdensetissues(e.g.lung)
allowthebeamtotravelthroughwithminimaldeflection;moredensetissues(e.g.bone)causethe
xraytoscatter.
Agridwithleadbarsinitremovesthescatteredbeamsbyabsorbingtherays
Finally,thebeaminteractswithanxraycassettecontainingafluorescentplatewhichemitslight
whenstruckbythexrayontoalightsensitivefilmcoatedwithsilvernitrateoraphosphorscreen
thatisscannedwithalaseroradirectCCDarrayfordigitalradiographs
Hence,morexray(lessdensetissue)darkerimage

HopkinsGeneralSurgeryManual 144
IIComputedTomography(CT)

Essentially,anadvancedformofconventionalxraywhereaseriesoftwodimensionalimages(or
slices)ofabodyareconstructedbyrotatingthexraysourceordetectoraroundthebody(thisgives
theinformationforagivenslice)andparalleltotheaxisofthebody(thisgivesinformationfrom
oneslicetoanother).Now,volumescansareobtainedasthepatientmovescontinuouslythrough
thescannerasthebeamrotatesaroundsubtendedahelixonthepatient.Thedataarecollectedas
avolumeandthencomputationallydividedintoslicesthataredisplayed.
Hounsfieldunits,namedafterSirGodfreyN.Hounsfield,theBritishengineerwhodevelopedthe
firstclinicallyusefulCTmachine(attheEMIcorporationwhichwasalsotherecordcompany
ownedbytheBeatlesatthetime.SirGodreywontheNobelPrize,unusualforanengineer),area
standardizedunitforreportinganddisplayingthereconstructedxraycomputedtomography
values.
Theyrangefrom1000forairto+3095forlead;wateris0;thisrepresents4096(or2
12
)bitstoo
manyforoureyestodistinguish.Insteadweget2
8
linearlydistributedbits
Twoparametersareselected:windowwidthandwindowlevel(i.e.whereitiscentered).For
example,awindowof(400,40)meansweseebetween160and+240;henceanything<160
blackandanything>+240white

Tissue H.U.
Air
Lung
Fat
Water
Kidney
Liver
Blood
Clottedblood
Corticalbone
1000
600
10010
0
30
50
3080
6080
5002000

[JOMeinternetjournal,KimandJiaw,1998]
HopkinsGeneralSurgeryManual 145

Usethegallbladderasaninternalstandardof0H.U.(i.e.water)

Ifthereiscontrastintheperitoneum,lookfor3things:

1.Rupturedviscous(generalrules)
Stomach:freeair,fluid
Smallbowel:freeair,fluid
Colon:freeair,fluid

2.Vesselextravasation:mustseeclotandcontrast(clottedbloodwillbebrighterthanliquidblood)onpre
contrast(butthereverseonpostcontrast)

3.Rupturedbladder(intraperitoneal):mustlookatdelayedviews

ThePouchofDouglasswillnormallyhold300400mLofbloodbeforeoverflowingusuallyto
MorrisonsPouchthentorightsubphrenicrecess

IIIMagneticResonanceImaging(MRI)

AnHatomcontainsasingleprotonandbehaveslikeaspinningbarmagnetthatwillalignwithamagnetic
fieldcreatedbythesolenoidoftheMRscanner.Beforearadiofrequency(RF)isappliedtheprotonsare
aligned.TheRFdeflectsthemsomenumberofdegreesfromtheZaxisofthemagnettheythenrelax
backtobeingaligned,although,theprotonsarespinningallthetimeattheLarmorfrequency.Thecoil
picksupthespinningmagneticcomponentthatisperpendiculartothemainmagneticfieldandinducesa
current(FaradaysLaw)thisisthesignalfromMRI.

TheRFfieldisappliedtothepatienttomakethebarmagnetstandupat90
o
(perpendicular)tothespine.A
wire(antenna)paralleltothespine,outsideofthepatientsbody,hasanalternatingcurrentformedinit,
whichdeterminesthesignalintensity.Themagnitudeofisproportionaltothenumberofprotonsandthe
extenttowhichtheirspinsareperpendiculartotheZaxis.Protonspredictablyrealignwiththespine,
whilecontinuingtopreceess.Sothereare2thingsatplayhere:

1.Theshorteninglengthofthespinningmagnet,and
2.Thelengtheningmagnetparalleltothespineasmoreandmoreprotonsrealign.

Thelongitudinal(orrestorationwiththemainmagneticfield)realignmentisknownasT1RELAXATION.
Itisaconstantforagiventissueand,bydefinition,itisthetimerequiredfor63%oftheprotonstorealign
withthemainmagneticfield.Itsexponential,soafter1T163%haverealigned,after2T1s86%have
realigned,after3T1s95%haverealigned,etc.[i.e.1(0.37)
3
]

Inreality,thespinningmagnetshrinksevenfasterthanpredictedbytheT1decaybecausethespinning
protonsactuallylosecoherenceandceasetospininunison.Thiscausessomeoftheremainingprotonsto
cancelouteachotherssignalandfurtherreducethesignalgeneratedintheantenna.Thisprocessof
protonsrandomlylosingcoherenceandcancelingouteachothersmagneticfieldsisknownasT2
RELAXATION.T1andT2areindependentofeachotherbutsimultaneousandT2relaxationisusually
muchfasterthanT1relaxation.Again,the63%decayischosentodescribetheconstantT2.Forexample,
after3T2shaveelapsedthenetstrengthofthemagneticfieldinthetransverseplanewillbe5%oforiginal
strength.

HopkinsGeneralSurgeryManual 146
MRIexploitsthefactthatdifferenttissuesandstatesofpathologyhavedifferentT1andT2.Themost
commonwaytodothisistoacquireimagesusingaspinechopulsesequence,where2parametersare
utilized:TR(repetitiontime)andTE(echotime).TRisthetimebetweenRFpulses.Thisisthetime
duringwhichT1relaxationoccurs.AttheendofTR,anotherRFpulseisappliedandthoseprotonsthat
haverealignedwiththemagneticfieldwillbebroughtupagainandproducecurrentintheantenna.SoTR
adjuststheamountofsignalreceivedfromatissuedependingonitsT1value(e.g.ifTR=3T1,thesignal
willbe95%intensity).

TEisthetimebetweenthefirstRFpulseandtheobservationofsignal,thatis,thetimeforT2relaxationto
occur.Forexample,settingTE=2T2wouldresultin15%netremainingsignalintensityproducedbythe
componentoftheprotonsinthetransverseplane.

Contrastbetweenthetwotissuescanbeproducedbytheinteractionofthetwoparameters.AverylongTR
willeliminatedifferencebetweentissueswithdifferentT1(e.g.TR=2500mswillallow5T1stoelapse
whetherT1is250msor500ms).AveryshortTEwouldsimilarlyminimizethedifferenceinT2decayby
differenttissues.

T1WeightedImageutilizesashortTR(tomaximizeT1contrast)andashortTE(tominimizeT2
contrast).AnatomicdefinitionissuperiortoT2weightedimages.Fatisdarkandfluidisbright
T2WeightedImageutilizesalongTR(tominimizeT1contrast)andalongTE(tomaximizeT2
contrast).Fatisbright,fluidisdark
PD(ProtonDensity)issomewherebetweenT1andT2.ItutilizesshortTE(1420ms)andlongTR
(4000ms)toeliminatedifferencesinT1andT2i.e.differencesareonlyduetotheprotondensity
ofeachtissue.Fatandfluidarebright.

HASTE(HAlffourierSingleshotTurbospinEcho),FLAIR(FLuidAttenuationInversionRecovery),STIR
(ShortT1InversionRecovery),etc.arevariousalgorithmsbasedondifferentTR/TEtimesandmethodsof
dataacquisition.However,thebasicprinciplesdescribedaboveremainthesame.

HopkinsGeneralSurgeryManual 147
IVPositronEmissionTomography(PET)

PETisafunctionalstudythatdetectsuptakeofvariousradioisotopes.Theisotopeusedmostcommonly
usedinclinical(surgical)applicationisF
18
,whichhasfavorablechemistry(similartoOH

)andareasonable
halflife(2hours).
18
FDGor2fluoro2deoxyDglucoseistreatedbymetabolicallyactivecellslikeglucose,
exceptthatitcannotbemetabolized.WhentheFDGmoleculeentersacell,theextraproton,whichcauses
thenucleustobeunstable,degradesintoaneutronandreleasesapositron(samemassasanelectron,but
withapositivecharge).Thisveryunstablepositronleavestheatomandtravelssomedistance,depending
ontheenergyatrelease(usually23mm),untilitcollideswithanelectron,resultingintheirmutual
annihilation.Two(almost)antiparallelphotonsarereleasedfromthereactionandtraveltoadetector
outsideofthebody

Nonpathologicalcellswithhighmetabolicrates(heart,brain,kidney,andliver)takeupFDGinadditionto
pathologiccells,suchastumorcells.HighFDGuptakeisnotalwayssynonymouswithmalignantdisease,
however,asothermetabolicallyactivecells,suchasthosefoundininfectionsandinflammatorylesions,
mayappearindistinguishablefromtumorlesionsbyPET.

[PhysicsofPET,Badawi,R,1999] [ScientificServices,1998]
HopkinsGeneralSurgeryManual 148
VUltrasound

Ultrasoundworksbyemittingabriefpulseofsound(atahighfrequency)andlisteningforthereturning
echofromthesurfacewithinthebody.
Audiblesoundisintherange:2020,000Hz
Ultrasoundisdefinedas>20,000Hz
Medical(diagnostic)ultrasoundoperatesbetween120MHz(e.g.AbdominalU/S35MHz)
Higherfrequencysuperiorresolution,butdecreasedpenetration
Themonitordistinguishesbetween256(2
8
)shadesofgrey:0(black)256(white)

Differenttissueswithinthebodyhavedifferentsoundtransmissioncharacteristics(acousticimpedances);
thedenserthetissuethefastersoundtravelsthrough

Material SoundVelocity(m/s)
Air
Fat
Water
Softtissue
Blood
Liver
Kidney
Bone
340
1450
1480
1540
1570
1535
1560
21004080

Greaterdifferencesinacousticimpedancebetweenadjacentsurfaces(acousticmismatch)determines
thestrengthofthereturningecho

WhileU/Shasseveraladvantages(nodeleterioussideeffects,inexpensive,fast)thereareseveral
drawbacks:
1. Soundwavespropagateverypoorlythroughgashence,U/Smusthaveagaslesscontactwiththe
bodyandorgan(s)ofinterest
2. U/Simagesareverynoisycomparedtoxray/MRimagesandproducepoorerimages
3. Operatordependence
4. Difficulttoquantify

HopkinsGeneralSurgeryManual 149
StatisticsinMedicine

TypeIError:Rejectthenullhypothesiswhenyoushouldnt(probability)

TypeIIError:Failingtorejectthenullhypothesiswhenyoushould(probability)

Power:TheprobabilityofavoidingTypeIIerror(1).Antherwayofsayingthis:Theabilityofyour
statisticaltesttodetectadifferencebetween2populationsshouldadifferenceexist.Seemoreonstatistical
powerbelow.

3BroadClassesofStatisticalPitfalls

ISourcesofBias
Includeerrorsofsamplingbias(studiedpopulationdosenotadequatelyrepresentpopulationofinterest)
anddatagathering(questionnaireswithleadingquestions).

IIErrorsinMethodology
Threemostcommoninclude:designingexperimentswithinsufficientpower(seebelow),failingtopay
attentiontoerrorsinmeasurement(understandthedifferencebetweenreliabilityandvalidity,seebelow),
andgoingonfishingexpeditions(makingmultiplecomparisons)withoutappropriatelycorrecting(seethe
Bonferronicorrection,below).

IIIInterpretationofResults(Misapplicationofstatisticalmethods)
Includeerrorsofstatisticalassumptions(e.g.usingamethodsuchasANOVAwhichreliesonassumptionsof
normalityandindependence,whensuchconditionsarenotmet),misunderstandingsofstatistical
significance,andassessingcausality(seebelow).

Reliability:theabilityofatesttomeasurethesamethingeachtimeitisused(Howclosearethedartsto
eachotherafterrepeatedlythrowingthematthedartboard?).Evenifthetestismeaningless,itshould
yieldthesameresultsovertimeifusedonsubjectswiththesamecharacteristics.

Validity:theextenttowhichatestmeasurestheoutcomeitwasdesignedtomeasure(Howclosearethe
dartstothecenterofthedartboard?).

Bonferronicorrection:astatisticaladjustmentforthemultiplecomparisonsoftenmadeduringstatistical
fishingexpeditions.Thiscorrectionraisesthestandardofproofneededtojustifythesignificanceofa
findingwhenevaluatingawiderangeofhypothesessimultaneously.Iftestingnoutcomes(insteadof1),
dividethebyn.Forexample,iftryingtofindtheassociationbetweenbodyweightand25differenttypes
ofcancer,dividedthetraditionalof0.05by25(0.05/25=0.002)toensureanoverallriskofTypeIerror
equaltoorlessthan0.05.Beaware,however,thatapplicationoftheBonferronicorrectioncanresultina
lossofsubstantialprecision.

Causality:Observationalstudiesareverylimitedintheirabilitytomakecausalinferences;doingso
requiresrandomassignment.Hence,correlationcanbeusedtoinfercausationiftheinterventionsare
randomlyassigned(e.g.doseofdrugvs.outcome).

HopkinsGeneralSurgeryManual 150
ThebelowPowerTable(toquotemylabmentor,isthesinglemostimportanttableforsomeonedoing
clinicalresearch)providesthenumberofsubjectsneededtoadequatelydetectadifferencebetweentwo
populations,shouldoneexist.Powerisadirectfunctionofthedegreetowhichthenullandalternative
distributionsoverlap(lessoverlapmorepower)and

Forexample,ifwithoutinterventiontherateofaninfectionis30%,andyouexpectyourtreatmentto
reduceitto20%,youwillrequire411patientsperarm(822intotal)tohave90%power,or313perarm(626
intotal)tohave80%power.Toarriveatthesenumbersfromthetablebelowdothefollowing:subtractthe
smallersuccessrate(0.20)fromthelargersuccessrate(0.30),0.300.20=0.10.Alignthiscolumnwiththe
rowcorrespondingtothesmallerofthe2successrates(inthisexample0.20).Thisleadsyoutothe
numbers411and313.Theuppernumberisthenumberofsubjects,perarm,requiredfor90%power,and
thelowernumberthenumberofsubjects,perarm,requiredfor80%power,withasignificanceof95%.
Glancingatthistablefromlefttorightyouseethatmoresubjectswillberequiredwhentheexpected
differencebetweenthetreatedanduntreatedgroupsissmaller.Thatis,thelessofadifferencethe
treatmentisexpectedtohave,themoresubjectsyouwillneedtofindadifference,shouldoneexist.

However,moreisnotalwaysbetter.Toomuchpowercanresultinstatisticalsignificancethatlacks
practicalsignificance.Inotherwords,ifthesamplesizebecomestoolarge,essentiallyanydifference
betweenthegroups,includingthosewithnopracticalsignificance,mayreachstatisticalsignificance.

[Cancer:Principles&PracticeofOncology5
th
,1999]
HopkinsGeneralSurgeryManual 151
Summaryofwaystoanalyzedata(i.e.WhichtestdoIuse?)

*ROC:ReceiverOperatorCharacteristiccurve(forthoseinterested,mathematicalexplanationoftheROC
curveisincludedbelow)
Withlogisticregression:values01negativeassociation;values>1positiveassociation
Withlinearregression:values<0negativeassociation;values>0positiveassociation

MultipleSamples

MeasuredData RankedData IndicationData

(e.g.counts)

Independent
Samples

Ttestifn30*

MannWhitneyUTest
(forsmallsamples)

Paired
Samples

Ttestifn30*

WilcoxanRank
(forsmallsamples)

SignsTest

*Forn<30toomuchvariancetousettestunlessyouknowthedistributionisnormalandtheselection
israndom

SummaryofClinicalTrials

PhaseI:Theirpurposeistodocumentthedoselevelatwhichsignsoftoxicityfirstappearinhumansto
determineasafe,tolerated,dose.Theendpointofsuchstudiesistoxicity.

PhaseII:Theirpurposeistodeterminetheoptimaldoseresponserangeforanewdrugandverifyits
efficacyfortheintendeddisorder.

PhaseIII:AfterphasesIandIIarecompleted,phaseIIItrialsareconductedandcontinueuntilthedrugis
releasedforgeneraluse.Theyfurtherverifytheefficacyofthedrug.

PhaseIV:FollowingFDAapproval,thesestudiesareoftenconductedinlargepopulationstofurtherdefine
theroleofthedrug/treatmentinspecialsubpopulations(e.g.children,elderly,pregnantwomen).

HopkinsGeneralSurgeryManual 152
ReceiverOperatorCharacteristic(ROC)Curve

Recall:
Sensitivity=TP/D+=TruePositive/TotalDisease+=TruePositiveRate(TPR)
Specificity=TN/D=TrueNegative/TotalDisease
1Specificity=1TN/D=(DTN)/D =FP/D
=FalsePositive/TotalDisease
=FalsePositiveRate(FPR)

Sometimestheresultsofatestfallintooneoftwoobviouslydefinedcategorieshence:one
sensitivity/specificitypair

Whatifthetestismorecomplicated?Forexample,useofCEAlevelasaprognostictoolfordecidingif
pancreaticcystfluidisfromabenignormalignantpancreaticcysticlesion.IfyoudecidethatalowCEA
willbeyourcutoffforacceptingthelesionasmalignant,youwillprobablynotmissanylesions,butwill
unnecessarilyresectmanybenignlesions.Conversely,ifyoudecideonaveryhighCEAasthecutoff,you
willlikelyonlyresectmalignantlesions,butwillcertainlymissmalignantlesionswithlowerCEAlevels.
Hence:
Asthecutoffdecreases SensitivityandSpecificity

TheROCcurveisdefinedasaplotoftestsensitivity(truepositiverate)astheycoordinateversusitsfalse
positiverate(1sensitivity)asthexcoordinate

Thisisaveryeffectivemethodofevaluatingtheperformanceofadiagnostictest.Whatdoesthislooklike?

AUC=AreaunderCurve
TestA(bestpossible):AUC=1
TestD(chancediagonal):AUC=0.5
Hence,
TestA>TestB>TestC>TestD
[KorenJRadiol,5:11,2004]
HopkinsGeneralSurgeryManual 153
AnalysisofSurvival

Thegoalofsurvivalanalysisistoestimatethesurvivalofapopulationbasedonasample.Thereare
severalmethodsfordoingthis,however,themostwidelyusedmethodisthatofKaplanMeier(infact,
theiroriginalarticle,JournaloftheAmericanStatisticalAssociation1958;53:457481,isoneofthetop5most
citedpapersinthefieldofscience).Thereasonthismethodissoimportant,inparticularforclinical
medicine,isbasedonthefactthatrarelyinanytrialarepatientsfollowedforthesamelengthoftime.
Patientaccrualtakesplaceovermonthstoyearsandpatientsleavethetrialforreasonsotherthestated
endpoints.However,theanalysisofsurvival(orsomeothermeasure,suchastimetodiseaserecurrence)
takesplaceatonepointintime,meaningthatnoteachpatienthasthesamelengthoffollowup.Hence,the
HolyGrailofsurvivalanalysisisonethatallowsustofollowapatientfortheentiretyoftheirtreatment
andfollowup,butremovethem(statistically)fromtheanalysiswhentheyleavethetrial.

Forexample,apatientparticipatesinatrialofananticanceragent,wheretheprimaryendpointofthetrial
issurvival,butislosttofollowup(i.e.leavesthetrial)at4years.Thefactthatthepatientlived4years
shouldcontributetothesurvivaldataforthefirst4years,butnotafterthat.However,youdontwantto
considerthepatientdeadat4years,sincetheymaystillbealiveandwell.Inclinicalpractice,mosttrials
haveaminimumfollowuptime,forexample,3years.Patientsleavingthetrialaliveinlesstimethanthis
willnotbeincludedintheanalysis.

Mathematicallyremovingapatientfromthesurvivalanalysisisreferredtoascensoringthepatient.When
patientsarecensoredfromthedata,thecurvedoesnottakeadownwardstepasitdoeswhenapatient
dies.Rather,ticks,onthehorizontallines,indicatewhencensoringoccurred.

Ateachtimeintervalthesurvivalprobabilityiscalculatedbydividingthenumberofpatientssurviving
bythenumberofpatientsatrisk.Patientswhohavedied,droppedout,ornotyetreachedthetimefor
minimumfollowuparenotconsideredtobeatrisk,andhence,arenotincludedinthedenominator.
Theprobabilityofsurvivingtoanypointisestimatedbytheproductofcumulativeprobabilitiesofeachof
thepreviousintervals.

Comparingsurvivalcurvesisoneofthemostimportantaspectsofsurvivalanalysis.Ifnosubjectswere
censoredinanyofthetreatmentarms,theWilcoxonranksumtestcanbeusedtocomparemediansurvival
times.However,ifcensoreddataarepresent(mostsituations)othermethodsmustbeusedtodetermineif
survivaldifferencesexist.Onesuchmethodcommonlyusedisanonparametrictechniqueknownasthe
logranktest.
[FiguretakenfromSTATA:StatisticalSoftwarefromProfessionals]
HopkinsGeneralSurgeryManual 154
Notes
HopkinsGeneralSurgeryManual 155
Notes
HopkinsGeneralSurgeryManual 156
Notes
HopkinsGeneralSurgeryManual 157
Notes
HopkinsGeneralSurgeryManual 158
Notes